Interleukin-15 is a hair follicle immune privilege guardian.

The autoimmunity-promoting cytokine, Interleukin-15 (IL-15), is often claimed to be a key pathogenic cytokine in alopecia areata (AA). Yet, rhIL-15 promotes human hair follicle (HF) growth ex vivo. We have asked whether the expression of IL-15 and its receptor (IL-15R) isoforms is altered in human AA and how IL-15 impacts on human HF immune privilege (HF-IP) in the presence/absence of interferon-γ (IFNγ), the well-documented key AA-pathogenic cytokine, as well as on hair regrowth after experimental AA induction in vivo. Quantitative immunohistomorphometry showed the number of perifollicular IL-15+ T cells in AA skin biopsies to be significantly increased compared to healthy control skin, while IL-15, IL-15Rα, and IL-15Rγ protein expression within the hair bulb were significantly down-regulated in AA HFs. In organ-cultured human scalp HFs, rhIL-15 significantly reduced hair bulb expression of MICA, the key "danger" signal in AA pathogenesis, and increased production of the HF-IP guardian, α-MSH. Crucially, ex vivo, rhIL-15 prevented IFNγ-induced HF-IP collapse, restored a collapsed HF-IP by IL-15Rα-dependent signaling (as documented by IL-15Rα-silencing), and protected AA-preventive immunoinhibitory iNKT10 cells from IFNγ-induced apoptosis. rhIL-15 even promoted hair regrowth after experimental AA induction in human scalp skin xenotransplants on SCID/beige mice in vivo. Our data introduce IL-15 as a novel, functionally important HF-IP guardian whose signaling is constitutively defective in scalp HFs of AA patients. Our data suggest that selective stimulation of intrafollicular IL-15Rα signaling could become a novel therapeutic approach in AA management, while blocking it pharmacologically may hinder both HF-IP restoration and hair re-growth and may thus make HFs more vulnerable to AA relapse.

Treatment of Paradoxical Adipose Hyperplasia following Cryolipolysis: A Single-Center Experience.

Paradoxical adipose hyperplasia is a rare adverse event associated with cryolipolysis. No evidence of spontaneous resolution has been described and little has been written about its treatment. The purpose of this report is to share the authors' experience treating patients with paradoxical adipose hyperplasia after cryolipolysis. A retrospective chart review was performed for all paradoxical adipose hyperplasia patients seen in the authors' practice between May of 2013 and May of 2016. The treatment parameters, demographics, onset of findings, and subsequent treatment were chronicled. Eleven cases of paradoxical adipose hyperplasia were identified (eight men and three women). All patients were of Hispanic background. Seven patients were treated surgically (six cases of liposuction alone and one case of liposuction and abdominoplasty). Average follow-up was 9.6 months (range, 2 to 32 months). Three of the patients treated with liposuction required a secondary procedure. All surgically treated patients were very satisfied with their final appearance. Paradoxical adipose hyperplasia is a rare complication of cryolipolysis that may occur more frequently than in the manufacturer's reported data. Treatment is best delayed until the affected area has softened, which normally occurs in 6 to 9 months after the initial cryolipolysis procedure. Power-assisted liposuction is the preferred method of treatment, but in some cases, abdominoplasty may be necessary. Secondary treatments might be needed for recurrence or persistent bulge. One must be sensitive to heightened patient concerns when offering an invasive procedure to correct the complications from a noninvasive one. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ocular Pain and Impending Blindness During Facial Cosmetic Injections: Is Your Office Prepared?

Soft tissue filler injections are the second most common non-surgical procedure performed by the plastic surgeon. Embolization of intravascular material after facial injection is a rare but terrifying outcome due to the high likelihood of long-term sequela such as blindness and cerebrovascular accident. The literature is replete with examples of permanent blindness caused by injection with autologous fat, soft tissue fillers such as hyaluronic acid, PLLA, calcium hydroxyl-apatite, and even corticosteroid suspensions. However, missing from the discussion is an effective treatment algorithm that can be quickly and safely followed by injecting physicians in the case of an intravascular injection with impending blindness. In this report, we present the case of a 64-year-old woman who suffered from blindness and hemiparesis after facial cosmetic injections performed by a family physician. We use this case to create awareness that this complication has become more common as the number of injectors and patients seeking these treatments have increased exponentially over the past few years. We share in this study our experience with the incorporation of a "blindness safety kit" in each of our offices to promptly initiate treatment in someone with embolization and impending blindness. The kit contains a step-by-step protocol to follow in the event of arterial embolization of filler material associated with ocular pain and impending loss of vision. 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 .

Embrace the Change: Incorporating Single-Stage Implant Breast Reconstruction into Your Practice.

BACKGROUND: Multiple studies have reported on the safety of nipple-sparing mastectomy and low complication rates associated with single-stage implant breast reconstruction. Yet many plastic surgeons continue to be resistant to change. This article presents the senior author's (M.A.C.) experience during his transition period from the latissimus dorsi flap with adjustable implants to a "one-and-done" approach using shaped implants and fetal bovine acellular dermal matrix. METHODS: A literature review was performed selecting articles discussing single-stage implant reconstruction, indications, outcomes, technique, and complications. Additional articles were selected after review of the references of identified articles. Clinical pearls discussed include patient selection, implant selection, and mastectomy incision choices, with a detailed description of the senior author's operative technique. RESULTS: Twenty-seven single-stage implant reconstructions were performed. Average mastectomy weight was 343.82 g. The average implant volume was 367 cc. Shaped implants were most commonly used. Acellular dermal matrix was used in all breasts. Complications included erythema requiring intravenous antibiotics (three patients), skin ischemia caused by methylene blue (one patient), seroma (one patient), unilateral partial nipple necrosis (one patient), mastectomy skin necrosis (one patient), and exposed/infected implants that were salvaged using a sequential irrigation protocol described by Sforza et al. in 2014 (two patients). CONCLUSIONS: Breast reconstruction after mastectomy has evolved toward less invasive, single-stage procedures. Aesthetic refinements include nipple-sparing mastectomy, use of acellular dermal matrix, shaped implants, and fat grafting. Selected patients will benefit from a one-and-done breast implant reconstruction with no additional oncologic risk. Surgeons must embrace the change and provide their patients with a procedure that will offer the best aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vaginal labiaplasty: current practices and a simplified classification system for labial protrusion.

BACKGROUND: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices. METHODS: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles. RESULTS: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined. CONCLUSIONS: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.

The management of pediatric type 1 nasoorbitoethmoidal fractures with resorbable fixation.

Nasoorbitoethmoid (NOE) fractures are rare in the pediatric population. A recent study reported that NOE fractures account for 1% to 8% of all pediatric craniofacial fractures based on the National Trauma Data Bank. Although infrequent, NOE fractures must be appropriately identified and treated because of potential severe esthetic and functional complications. In this report, we discuss our experience treating the uncommon case of a 9-year-old girl who was involved in a motor vehicle accident and had traumatic injuries to the midface, including a type 1 NOE fracture. We elected to use biodegradable plates to treat her left type 1 NOE fracture because of concerns of facial growth disturbances with the use of conventional rigid fixation techniques at her young age. At 1-year follow-up, the patient demonstrated an acceptable outcome with no functional problems reported. We have also incorporated in this article a thorough review of the literature relating the evolution of biodegradable plates for the treatment of pediatric facial fractures.

The impact of a standardized consultation form for facial trauma on billing and evaluation and management levels.

BACKGROUND: Facial trauma is among the most frequent consultations encountered by plastic surgeons. Unfortunately, the reimbursement from these consultations can be low, and qualified plastic surgeons may exclude facial trauma from their practice. An audit of our records found insufficient documentation to justify higher evaluation and management (EM) levels of service resulting in lower reimbursement. Utilizing a standardized consultation form can improve documentation resulting in higher billing and EM levels. METHODS: A facial trauma consultation form was developed in conjunction with the billing department. Three plastic surgery residents completed 30 consultations without the aid of the consult form followed by 30 consultations with the aid of the form. The EM levels and billing data for each consultation were obtained from the billing department for analysis. The 2 groups were compared using χ2 analysis and t tests to determine statistical significance. RESULTS: Using our standardized consultation form, the mean EM level increased from 2.97 to 3.60 (P = 0.002). In addition, the mean billed amount increased from $391 to $501 per consult (P = 0.051) representing a 28% increase in billing. CONCLUSIONS: In our institution, the development and implementation of a facial trauma consultation form has resulted in more complete documentation and a subsequent increase in EM level and billed services.