Potential role of the common food additive manufactured citric acid in eliciting significant inflammatory reactions contributing to serious disease states: A series of four case reports.

Citric acid naturally exists in fruits and vegetables. However, it is not the naturally occurring citric acid, but the manufactured citric acid (MCA) that is used extensively as a food and beverage additive. Approximately 99% of the world's production of MCA is carried out using the fungus Aspergillus niger since 1919. Aspergilus niger is a known allergen. The FDA placed MCA under the category of GRAS without any research to substantiate this claim. In 2016, 2.3 million tons of MCA were produced, predominantly in China, and approximately 70% is used as a food or beverage additive. There have been no scientific studies performed to evaluate the safety of MCA when ingested in substantial amounts and with chronic exposure. We present four case reports of patients with a history of significant and repetitive inflammatory reactions including respiratory symptoms, joint pain, irritable bowel symptoms, muscular pain and enervation following ingestion of foods, beverages or vitamins containing MCA. We believe that ingestion of the MCA may lead to a harmful inflammatory cascade which manifests differently in different individuals based on their genetic predisposition and susceptibility, and that the use of MCA as an additive in consumable products warrants further studies to document its safety.

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift.

BACKGROUND: Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated. OBJECTIVES: The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift. METHODS: In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic. RESULTS: From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men). CONCLUSIONS: Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning.

A Review of Body Dysmorphic Disorder in Aesthetic Surgery Patients and the Legal Implications.

BACKGROUND: Body dysmorphic disorder (BDD) is an often under-recognized yet severe psychiatric illness. There is limited guidance for plastic surgeons in the USA in how to recognize and manage patients with BDD and protect themselves from potential litigation and harm. Therefore, in collaboration with legal counsel, we remind our profession of the serious nature of patients with BDD, provide warning signs for recognizing BDD, and critically evaluate the validity of informed consent and the legal ramifications of operating on such patients in the USA. METHODS: A literature review was performed to clearly define the psychopathology of BDD and identify cases of patients with BDD who underwent cosmetic surgery resulting in potential threats to the surgeon. An additional search of the legal literature was performed in collaboration with legal counsel to identify key cases of patients with BDD attempting litigation following cosmetic surgery procedures. RESULTS: The diagnostic criteria and psychopathology of BDD are presented. Warning signs are highlighted to alert the plastic surgeon to patients at high risk for BDD. Strategies for legal protection include a pre-procedure checklist for patients that are suspected of having a BDD diagnosis. CONCLUSION: Body dysmorphic disorder is prevalent in the cosmetic surgery population. Patients with BDD often have a poor outcome following aesthetic surgery, which can result in a dangerous or even deadly situation for the surgeon. We aim to remind aesthetic plastic surgeons of the psychopathology, severity, and specific risks associated with operating on patients with BDD while suggesting specific protective strategies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .