Dexamethasone Mesotherapy: An Alternative for Keloid Treatment in Hispanic Skin.

The incidence of keloids in individuals with skin of color is as high as 16%. Intralesional steroid injection is recommended as a first-line treatment, even though the outcomes are often suboptimal. Histologically, the keloid epidermal layer is thicker than in normal skin, and the vascular density is higher in the marginal area at subepidermal level due to the elevated expression of vascular endothelial growth factor. Dexamethasone significantly suppresses this proangiogenic cytokine compared with Triamcinolone. We report the case of a 32-year-old phototype VI man with a 6-month-history of a keloid on the dorsum of his right hand that caused functional and cosmetic morbidity. We performed an intralesional injection of dexamethasone using a mesotherapy technique, that led to significant shrinking and complete recovery of range of motion after two sessions, with no regrowth at the 1-year follow-up. Mesotherapy is a safe and easy technique used in cosmetic medicine, which allows for a slower diffusion of dexamethasone and prolongs its pharmacological action, reducing the risk of local side effects. This technique has the potential to be standardized, but its main drawback is the need for proper sedation. Randomized clinical trials are required to further evaluate the clinical efficacy of dexamethasone mesotherapy.

Percutaneous Intradermal Purse-String closure for Correction of Male Tuberous Nipple-Areola Complex Deformity.

BACKGROUND: Male tuberous breast is an exceedingly rare condition that not fit properly into the majority of existing classifications of gynecomastia. This deformity has been categorized by Cordova and Moschella as gynecomastia grade III; however, they do not make any reference to the isolated tuberous deformity of the nipple-areola complex (NAC). Considering that the areolar area is the main ''esthetic unit'' in the male chest, surgical correction of the isolated tuberous NAC deformity can be challenging. There is a belief that this deformity is unsuccessfully corrected when approached through a limited periareolar incision at the lower pole. A complete periareolar incision, with a concentric excision of excess areolar skin, is usually required leaving an unnatural-looking round periareolar scar on the male thorax. METHODS: We describe a variation of a surgical technique for the correction of a male tuberous NAC deformity in a teenager who rejected a conspicuous round periareolar scar after surgery. This modification combines a conventional lower hemiareolar approach with a percutaneous intradermal purse-string suture in the superior areolar margin to reduce the areolar diameter, avoiding an evident circumareolar scar. RESULT: At the six-month follow-up, areolar widening or tuberous deformity relapse was not observed. The patient felt satisfied with the outcome. CONCLUSION: The use of percutaneous intradermal purse-string periareolar suture for correction of this rare deformity is a simple and reproducible surgical technique that could help to obtain a better cosmetic result by restoring the contour of the male chest while minimizing the visibility of the residual scar. LEVEL OF EVIDENCE V: 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 .

Back to Basics: Could the Preoperative Skin Antiseptic Agent Help Prevent Biofilm-Related Capsular Contracture?

BACKGROUND: Capsular contracture (CC) has remained an unresolved issue throughout history. Strong evidence focuses on bacterial biofilm as its main source. A literature review revealed that more than 90% of bacteria found in capsules and implants removed from patients with Baker grade III-IV CC belong to the resident skin microbiome (Staphylococcus epidermidis, predominant microorganism). The use of an adequate preoperative skin antiseptic may be a critical step to minimize implant contamination and help prevent biofilm-related CC. OBJECTIVES: The authors sought to compare the effect of 2 different antiseptic skin preparations: povidone-iodine (PVP-I) vs chlorhexidine gluconate (CHG) on CC proportions after primary breast augmentation through a periareolar approach. METHODS: In June of 2014, The Society for Healthcare Epidemiology of America proposed to use CHG for preoperative skin preparation in the absence of alcohol-containing antiseptic agents as strategy to prevent surgical site infection. The clinical safety committee of a surgical center in Colombia decided to change PVP-I to CHG for surgical site preparation thereafter. The medical records of 63 patients who underwent to primary breast augmentation through a periareolar approach during 2014 were reviewed. In the first 6 months PVP-I was used in 32 patients, and later CHG was employed in 31 patients. RESULTS: Pearson's chi-squared test to compare CC proportions between subgroups showed a statistically significant difference. The CC proportion was higher for patients who had antisepsis with PVP-I. CC was absent when CHG was employed. CONCLUSIONS: CHG as preoperative skin antiseptic for primary breast augmentation surgery was more effective than PVP-I to help prevent biofilm-related CC.

IL-10 Prevents apoptosis of brain endothelium during bacteremia.

IL-10-deficient mice infected with the relapsing fever bacterium Borrelia turicatae rapidly succumb to a brain hemorrhage if they are unable to clear peak bacteremia. In this study, we investigated the protective role of IL-10 during relapsing-remitting bacteremia and explored the molecular events involved in the protection of brain endothelium by IL-10. Brain endothelial injury was measured with cytotoxicity and diverse apoptotic assays, whereas the signaling pathway analysis was done by quantitative PCR array. The results showed that severe endothelial cell injury leading to hemorrhage in the brain and other organs occurred in IL-10-deficient mice during relapsing-remitting infection. Human brain microvascular endothelial cells (HBMEC) produced abundant proinflammatory mediators upon exposure to whole bacteria or purified bacterial lipoprotein but did not produce any detectable IL-10. Whole bacteria and purified outer membrane lipoprotein rapidly killed HBMEC by apoptosis in a time- and concentration-dependent manner. Exogenous IL-10 protected HBMEC from apoptosis. HBMEC apoptosis during exposure to a low number of bacteria was associated with downregulation of TNF and TNFAIP3 and upregulation of BAX. In contrast, HBMEC apoptosis during exposure to high concentrations of purified outer membrane lipoprotein was associated with marked upregulation of FAS, FAS ligand, and the adaptor molecules RIPK1 and CFLAR. Exogenous IL-10 reversed all the apoptotic signaling changes induced by whole bacteria or its purified lipoprotein. The results indicate that prominent brain endothelial cell apoptosis occurs during relapsing-remitting bacteremia in the absence of IL-10 and point to a prominent role for bacterial lipoprotein-mediated activation of FAS and caspase-3 in this process.

Mammographic findings after breast augmentation with autologous fat injection.

BACKGROUND: Conventional film-screen mammography is a highly effective tool for the early diagnosis of breast cancer. Although the mammographic spectrum of fat necrosis has been well documented, and many postsurgical findings mimic carcinoma in clinical examination or imaging studies, the evolution of the mammographic appearance has not previously been reported in patients with a history of breast lipoinjection. OBJECTIVE: The purpose of our study was to evaluate the mammographic findings of fat necrosis in patients who had undergone breast lipoinjection and to determine whether there are any specific features that help to distinguish fat necrosis caused by fat injection from more worrisome findings. METHODS: Bilateral mammography was performed on 20 patients who had received autologous fat injection for breast augmentation between February 1999 and June 2006. The time elapsed between surgery and the postoperative mammograms ranged from 6 months to 7 years, an average of 34.5 months. The mammographic findings of fat necrosis were divided into six categories: 1, radiolucent oil cysts; 2, microcalcifications; 3, coarse calcifications; 4, focal masses; 5, spiculated areas of increased opacity; 6, negative. The Breast Imaging Reporting and Data System (BI-RADS) was used to classify the lesions in the mammograms. RESULTS: The most common mammographic findings were benign bilateral scattered microcalcifications, followed by dispersed radiolucent oil cysts in the breast tissue. Microcalcifications were found on the mammogram of one patient as early as 11 months after lipoinjection. Only 3 patients showed clustered microcalcifications on their mammograms and were classified as BI-RADS III. These patients were later available for further digital mammography and reclassified as BI-RADS II. CONCLUSIONS: Knowledge of the mammographic appearance and evolution of patterns of fat necrosis in patients who have undergone breast fat injection may enable imaging follow-up of these lesions, reducing the number of unnecessary biopsies or additional examinations and avoiding possible delays in the diagnosis of breast cancer. Because calcifications in breast parenchyma can be expected after breast fat injection, in our opinion this technique for breast augmentation should not be performed in patients with a family history of breast cancer.

Interleukin 10 protects the brain microcirculation from spirochetal injury.

Spirochetal infections are an important cause of neurological disease. In previous studies of the pathogenesis of spirochetal brain infection, mice inoculated with Borrelia turicatae, an agent of tick-borne relapsing fever in North America, developed mild meningitis and parenchymal activation/infiltration by interleukin 10 (IL-10)-producing microglia/macrophages. Here, we investigated the neuroprotective effects of IL-10 during spirochetal infection by comparing the outcomes of B. turicatae infection in wild-type and IL-10-deficient RAG2-deficient mice. Mice were infected with either serotype 1 (Bt1), which causes more brain infection but lower bacteremia, or Bt2, which causes less brain infection but higher bacteremia. Interleukin 10 deficiency resulted in early death from subarachnoid/intraparenchymal brain hemorrhage in Bt2-infected mice. These mice had marked apoptosis of brain microvascular endothelial cells as assessed by terminal transferase-mediated DNA nick end-labeling staining. In contrast, Bt1 infection caused milder subarachnoid hemorrhage. Neuronal apoptosis was observed in mice infected with both serotypes and was prominent in the cerebellum. Neutralization of tumor necrosis factor prevented death and reduced morbidity and brain injury in mice infected by both serotypes. We conclude that IL-10 plays a critical role protecting the cerebral microcirculation from spirochetal injury possibly by inhibition effects of tumor necrosis factor.

Refinement of rhinoplasty with lipoinjection.

BACKGROUND: The most common aesthetic defects after rhinoplasty are small dorsal irregularities observed mainly in patients with thin dorsal nasal skin. Many techniques have been used in attempts to prevent perceptible irregularities and sharp edges of bone and cartilage in these patients. Adipose tissue transplantation has been used widely in aesthetic surgery as a surgical method to correct surface depression or to augment soft tissue. Recently, this tissue has been considered a potential source of stem cells with regenerative capacity and other benefits. The authors present a simple procedure using lipoinjection of microfat grafts over the osseocartilaginous framework of the nasal dorsum as a routine technique in rhinoplasty. METHODS: Open rhinoplasty was performed for all the patients. At the start of the procedure, we aspirated 3 to 5 ml of fat and separated it using the sedimentation method. The fat deposited as sediment (2-3 ml) was injected at the beginning of the procedure, after suture of the incisions and before application of the splint, over the osseocartilaginous framework in the subcutaneous space. The fat acted as a thin layer of soft tissue to thicken the overlying skin and help camouflage minimal imperfections. RESULTS: Between February 2003 and May 2005, 78 rhinoplasties were performed, with injection of autologous fat. Of the 78 patients, 61 were primary rhinoplasties and 17 were secondary rhinoplasties with a follow-up time of 1 to 36 months. No minor irregularities were observed, and the aspect and quality of the skin improved for all the patients. CONCLUSIONS: Fat injection into the nose as a refinement of rhinoplasty is a fast, easy, inexpensive procedure for obtaining regular and smooth contours on the nasal dorsum that lasts over time.

Securing nasal tip rotation through suspension suture technique.

BACKGROUND: Multiple techniques have been described to produce tip rotation in rhinoplasty, including the use of sutures, a technique popularized by several authors and shown to be predictable, controllable, and nondestructive. The authors describe a simple procedure for nasal tip rotation with a suture suspension technique through a closed method that allows the nasal tip to be rotated while maintaining its appropriate position. METHODS: In each case, after the authors performed standard rhinoplasty techniques, the osteocartilaginous junction was used as an anchor for their suture suspension technique. This technique requires the use of a guide that positions the sutures across the medial side of both domes of the alar cartilages and osteocartilaginous junction. RESULTS: Between September of 2002 and September of 2004, this technique was used in 30 patients with nasal tip ptosis who requested improvement of this condition. There were 21 primary rhinoplasty and nine secondary rhinoplasty procedures. The results were satisfactory in all of the patients, but four patients had minimal asymmetries of the tip. In the follow-up of these patients, the projection of the nasal tip was maintained long term. CONCLUSION: With this suspension suture technique, the authors were able to maintain the optimal position of the nasal tip, using the osteocartilaginous junction as a pillar to provide long-term stability of the nasal tip.

Alternative technique for tip support in secondary rhinoplasty.

BACKGROUND: Re-establishing nasal tip projection is one of the main objectives in secondary rhinoplasty. The columellar strut is used as a basic element for support and the septal cartilage graft as the first choice for reconstruction. Nevertheless, the septal cartilage is often missing in this category of patient because of previous surgery, obliging the surgeon to seek a safe, effective, and versatile alternative. OBJECTIVE: We describe a simple procedure to increase the strength of an autologous ear graft cartilage to be used as a columellar strut in patients having secondary rhinoplasty. METHODS: We removed a 3.5 x 1.5-cm auricular concha graft through a postauricular approach, leaving the perichondrium on the posterior surface and trimming it on the helical crus. Later, we made a cylinder-shaped structure to be used as a columellar strut graft in patients in whom the septum was absent. We used the open rhinoplasty technique, applying the basic principles of secondary rhinoplasty, in all of the patients. RESULTS: Between February 2002 and June 2006, we used this technique in 13 patients ranging in age from 19 to 52 years who required revision rhinoplasty. The clinical follow-up period ranged from 4 to 48 months. Five of the patients experienced minor complications; nevertheless, all were satisfied with the postoperative results. CONCLUSION: The auricular cartilage struts constructed using this method were strong enough to enhance tip support and projection, with satisfactory results assessed by both the patients and our team.

Alternative technique for breast augmentation in patients with a small nipple-areolar complex diameter.

BACKGROUND: The use of the periareolar incision in breast augmentation procedures results in inconspicuous scarring. However, this approach is problematic when treating a patient with a small nipple-areolar complex (NAC) diameter. OBJECTIVE: We describe a simple procedure for breast augmentation in patients with a small NAC diameter that uses an alternative periareolar approach to produce a scar similar to that resulting from the conventional periareolar incision. METHODS: The conventional periareolar approach requires an areolar diameter of at least 3 cm for breast augmentation. We utilized geometric calculations to obtain values of perimeters and areas of hemi-ellipses for circles with diameters between 2 and 2.9 cm that are similar to the values calculated for a circle 3 cm in diameter. We applied the findings to our surgical technique. A crescent moon-shaped incision was made using a zigzag pattern on the hemiareolar inferior border, and the epidermis was removed from this area. The dissection was made through the mammary parenchyma and by way of the external arch. The inframammary crease was lowered enough so that the implant would be centered under the nipple when the incision was closed. A silicone gel-filled implant was inserted, and the lower edge of the incision was overlapped onto the deepithelialized upper flap, allowing the edges of the wound to join and seal in layers without requiring a purse-string support. RESULTS: Between June 2002 and June 2004, we used this technique in 10 patients with areolar diameters ranging from 2.2 to 2.8 cm who requested primary breast augmentation with either cohesive gel or liquid silicone gel-filled implants. The resulting scar was satisfactory in color and quality for 8 patients; 2 patients had lateral widening of the scar. There was a slight change in the areolar diameter compared to the original diameter in all patients, but there were no deformities. CONCLUSIONS: This simple procedure is an effective alternative technique for breast augmentation surgery in patients with a small NAC diameter.

Estudio de 224 donantes de riñón para trasplante con evaluación de calidad de vida posdonación en un subgrupo

Estudiamos los registros clínicos de 224 donantes de riñon para traspnate intrafamiliar, quienes fueron sometidos a nefrectomía (Nx) unilateral en nuestro hospital, entre agosto 1973 y febrero 1989. La edad promedio fue 31+- (ESM) años (rango 16-59); 123 (55 por ciento) fueron hombres y la relación donante-receptor fue : hermanos 162 (72 por ciento), padres 38 (17 por ciento) e hijos 24 (11 por ciento). La Nx fue 5.7+-0.3 días (rango 3-25). Buscamos la mayor parte de estos 224 donantes mediante cartas, llamadas y mensajes enviados a través de sus respectivos receptores; 140 (62 por ciento) respondieron. A este subgrupo se le interrogó sobre problemas médicos a partir de la Nx, se les practicó examne físico completo y se les hicieron prubas de función renal en nuestro laboratorio o en sus lugares de residencia. Comparamos los resulatdos con los de pre-Nx. La duración del seguimiento fue 51.1+-2.9 meses (rango 0.3-198). Ochenta y seis de los 140 respondieron un cuestionario sobre calidad de vida y actitudes frente a la donación. Para pre y post-Nx respectivamente, el paso fue 61.1+-0.7 y 63.2+- 1 Kg (NS), la presión arterial sistólica 123+-0.8 y 126+-1.4 mmHg (NS) y la diastólica 78+-0.5 y 79+-0.9 mmHg (NS). Los resulatdos de las pruebas de laboratorio pre y post-Nx fueron : creatinina 1.05+-0.2 y 1.29+-0.2 mg/dl (P<0.00001), nitrógeno ureico 10.3+-3.5 y 15.1+-5.3 mg/dl (P<0.00001), depuración de creatinina 94.3+-24.2 y 84.6+-18.2 ml/min (P=0.00021), y proteinuria 0.08+-0.12 y 0.07+-0.13 g/día (NS). Se hallaron valores de proteinuria post-Nx mayores de 0.3 g/día en 19 de 107 en los que se determinó (18 por ciento), con un valor máximo de 0.57 g/día. Hipertensión post-Nx ocurrió en tres casos (2.1 por ciento)...