Castleman disease. Interaction with dermatopathy: Case report

INTRODUCTION

Castleman disease (CD) is a lymphoproliferative disorder with lymph node hypertrophy. In the unicentric form (UCD), it affects one lymph node or chain of lymph nodes. In the multicentric form (DCM), there is hypertrophy of several lymph node chains with the formation of tumor masses, causing compressive symptoms. This case report showed a case of CD in a different location(inguinal region) associated to a multiple skin lesions.

PRESENTATION OF THE CASE

We reported a UCD in a 43-year-old female patient with no previous comorbidities. Since January 2016, this patient developed erysipelas lesions of the left leg (LL) from the thigh root to the foot. Concomitantly, a tumor mass appeared in the inguinal region. In 2019 we performed a biopsy that revealed changes characteristic of CD. Due to extremely poor trophic conditions, the skin area with erysipelas was resected, and the raw surface was grafted.

DISCUSSION

As an inference, the erysipelas may have been responsible for the subsequent lymphangitis, lymphedema and lymph node hypertrophy.

CONCLUSION

Resection of the diseased skin and lymph node excision constitute the treatment of UCD and result in improvement of the clinical picture. Nevertheless, further study of the inflammatory reaction and of markers such as interleukin-6 and the presence of skin disorders in DC is needed.

Study of the Effect of Hyperbaric Oxygen Therapy on the Viability of Dorsal Cutaneous Flaps in Tobacco-Exposed Rats

BACKGROUND

Smoking causes a threefold increase in the risk of surgical complications in flaps. Hyperbaric oxygen therapy (HBOT) increases the viability of chronic wounds. However, there are few studies concerning the effects of HBOT on surgical flaps in patients who smoke. This study aimed to analyze the effect of HBOT on the viability of cutaneous flaps in tobacco-exposed rats.

METHODS

Twenty Wistar rats were exposed to tobacco smoke for two months. Following this period, all animals underwent a dorsal cutaneous flap (3 × 10 cm) surgery and were divided into two groups: control (n = 10) and HBOT (n = 10). HBOT was performed in seven daily sessions (2 ATA, 90 min). After seven days, the animals were euthanized. The outcomes were total area, viable area, viable area/total area rate, analysis of dermal appendages and angiogenesis (hematoxylin-eosin), and gene expression analysis of iNOS and VEGF-a biomarkers.

RESULTS

The HBOT group showed an increase in viable area compared with the control group (84% versus 47%, p = 0.009, respectively). The HBOT group also showed an increase in appendage units (1.69 ± 0.54 versus 1.87 ± 0.58, p = 0.04) and angiogenesis density (1.29 ± 0.45 versus 1.82 ± 0.64, p < 0.001) compared to the control group. There was a difference between the control and HBOT groups in iNOS levels (0.926 ± 1.4 versus 0.04 ± 0.1 p = 0.002, respectively). However, this study did not show a difference between the groups concerning the gene expression of VEGF-a.

CONCLUSION

The use of hyperbaric oxygen therapy increased the viability of cutaneous flaps in tobacco-exposed rats and decreased iNOS mRNA levels; however, it did not change VEGF-a levels. Level of Evidence IV 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.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AIMS

To quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection.

METHODS

Three hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic).

RESULTS

Altered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02).

CONCLUSIONS

Numeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

Effects of retinoic and glycolic acids on neoangiogenesis and necrosis of axial dorsal skin flaps in rats

Retinoic acid (RA) and glycolic acid (GA) are frequently used in the treatment of acne and skin aging, as well as improving skin healing after dermabrasion and in photoaged skin. Examples of histologic alterations caused by these substances are vascularization increase and interference with inflammatory as well as regenerative skin processes. The objective of this study was to evaluate the possible decrease of skin flap necrosis areas in rats, by applying both substances to the skin 14 and 30 days before surgery, and analyzing histopathologic skin alterations after treatment. Fifty Wistar rats were divided into five groups of 10 animals each. They received daily retinoic acid application for 14 and 30 days, daily glycolic acid application for 14 and 30 days, and vehicle application (control group) for 14 days. After treatment, each rat was submitted to random dorsal skin flap (10 x 3 cm) elevation; flaps were sutured back in place over isolating plastic strips. The rats were sacrificed after 7 days and flap necrosis areas were measured through transparency and then analyzed using computer scanning. Statistical analysis was carried out using monocaudal nonpaired t tests and histopathologic examination was performed in all cases. Compared with the control group, treatment with both acids did not decrease average flap necrosis areas. Though groups RA 30 days and GA 14 days presented larger necrosis area averages (p < 0.05), groups RA 14 days and GA 30 days showed no statistically significant difference (p > 0.05) when compared to the control group. Both substances caused spongiosis, stratum corneum thickening, and vascularization increase, with GA inducing greater granulomatous reaction and RA more spongiosis and queratinization. Group RA 30 days showed the most significant dermo-epithelial (including vascular) regenerative and proliferative effects. Retinoic and glycolic acid treatment led to significant and well-known skin alterations, with group RA 30 days showing most notable dermo-epithelial proliferative effects. In our experimental model, preoperatory RA and GA application did not decrease rat dorsal skin flap necrosis area when compared to the control group.

Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot

Cutaneous injuries of the inferior third of the leg and dorsum of the foot represent a great challenge for plastic surgeons. The poor vascularization and subsequent poor healing encountered in these regions demand detailed knowledge of the local anatomy to select the best surgical alternative for each patient. In patients in whom local or free muscular flaps are not suitable, the fasciocutaneous flaps seem to be a good alternative. The distal pedicled fasciocutaneous flap of the calf was used to cover skin defects of the leg and foot in 22 patients. In 4 patients the authors designed an island flap to prevent a large defect in the donor area and to decrease the time of hospitalization and recovery of the patient. In a severe defect, the flap was used as a cross-leg flap. The results were satisfactory because the flap provided stable coverage for different defects with few complications. The island flap is a good option for achieving a better aesthetic result and can be used in select patients.

The role of plastic surgery in congenital cutis laxa: a 10-year follow-up

The clinical features and the plastic surgery management of a 23-year-old woman with cutis laxa are presented. Two rhytidectomies were performed in this patient within 1 year. The first was associated with a SMAS flap; the second employed a prehairline incision. The evolution of the aging facial appearance 10 years after the last face lift was evaluated and compared with the preoperative situation. Repeated face lifts seem to be an interesting way to manage patients with cutis laxa. Unlike patients with other disorders of the connective tissue, those with cutis laxa have no vascular fragility and heal well. The role of plastic surgery and the clinical features and timing for operation are reviewed and discussed.

A study of the post-burned restored skin

The color of restored skin (RS) resulting from healing of partial skin thickness burns was analyzed. Comparisons within symmetric skin areas were performed between RS and healthy undamaged skin (HS), using spectrophotometry, in 118 subjects, 64 males, 54 females with an age range of 1-70 years. A total of 379 samples were analyzed. The CIE-1976 color system was adopted where L*, a* and b*, characterizes the sample color. L*, a* and b* values from restored and healthy skin were obtained and differences between them calculated. Age, sex, sun exposure and time span after burn were taken into account and the data was submitted to statistical analysis: Wilcoxon test for age and chi 2 for other variables. RS became darker: one year after the original burn; in subjects with sun exposure and in older subjects. Sex did not show any influence on brightness index. RS became more red in subjects with sun exposure; in older subjects; within the first six months after the burn. Sex did not show any influence on a* chromaticity axis. RS became more blue: in male subjects and within one year after the burn. Age and sun exposure did not yield any influence on b* chromaticity axis.

Correction of eyelid anomalies in pachydermoperiostosis

PURPOSE

Pachydermoperiostosis, or primary hypertrophic osteoarthropathy, is a rare disease, characterized by pachydermia, acropathy, and periostosis. The authors propose the surgical correction of the eyelid anomalies in one stage.

METHODS

A 30-year-old patient with moderate blepharoptosis (3 mm) and increased vertical and horizontal dimensions of the upper eyelids underwent fusiform transverse excision of skin, orbicularis muscle, and tarsus; shortening of the levator palpebrae superioris apeoneurosis by 13 mm; and 8-mm-wide wedge excision.

RESULTS

Histologic findings included hyperplasia of the tarso-conjunctival plate, obstructive cystic dilatation of the sebaceous glands, extensive fibrosis, and granulomatous reaction. Satisfactory functional and aesthetic results were observed after surgery.

CONCLUSION

Upper eyelid anomalies in pachydermoperiostosis can be corrected in a single stage bilaterally with good results.

Abdominal wall closure after selective aponeurotic incision and undermining

The tension required to pull the anterior and the posterior rectus sheaths toward the midline was studied in 20 fresh cadavers at two levels: 3 cm above and 2 cm below the umbilicus. The quotient of the force used to mobilize the aponeurotic site to the midline and its resulting displacement was called the traction index. These indices were compared in three situations: (1) prior to any aponeurotic undermining, (2) after the incision of the anterior rectus sheath and the undermining of the rectus muscle from its posterior sheath, and (3) after additionally releasing and undermining the external oblique muscle. A significant decrease in aponeurotic resistance was observed after each dissection. The anterior sheath showed higher resistance to traction compared with the posterior sheath on both levels. No statistical difference was noted in the comparison of the values of the aponeurosis above and below the umbilicus. These results suggest that these procedures are effective in assisting in the closure of abdominal wall defects because these maneuvers decrease substantially the tension required for advancement of the aponeurotic edges.

Contraction and myofibroblasts in restored skin

Myofibroblasts and the contraction of split skin-graft donor sites were studied in 18 patients. For each patient five samples were studied, taken on days 0, 14, 21, 28, and 35. On each occasion the extensions and densities of myofibroblasts were calculated. After the initial measurement, the subsequent extensions were expressed in percentages of the first, resulting in mean measurements of 100, 95, 97, 99, and 99%, respectively. The myofibroblasts in 10 dermic fields were counted under light microscopy at a magnification of 1000 marked with anti-alpha-smooth muscle actin antibodies using immunoperoxidase, resulting in the means of 0.2, 3.8, 1.3, 1.3, and 0.4, respectively. The contraction and the increase in density of myofibroblasts were transitory and significant in the samples measured on day 14, but in sample 35 neither of the variables was significantly different from the initial sample. These variables evolved concurrently, corroborating the hypothesis that myofibroblasts are responsible for the contraction.

[Kinetic distribution of cyclosporine after single dose subcutaneous administration; experimental study in rats]

Adequate dose of cyclosporin A shows immunosuppressor effect, and low toxicity. The doses reported previously ranged from 2.5 to 25 mg/kg every 24, 48 hours and even 7 days. Routes for cyclosporin A administration are subcutaneous or intramuscular preferentially. In the present study, cyclosporin A (CSA) single dose subcultaneous was administered to 21 Wistar-Furth rats, adult, males, weighing 350-450g. The animals were divided in 3 groups receiving 2.5 mg/kg (group 1), 5.0 mg/kg (group 2) and 10.0 mg/kg (group 3). Blood samples were collected at 1, 4, 8, 12, 24, 48 and 72 hours after drug collection into plastic tubes containing sodium EDTA. Blood cyclosporin A levels were determined by a commercially available radioimmunoassay kit (Sandoz RIE Kit Basel) after whole hemolysis using liquid nitrogen. Cyclosporin A blood concentrations vs time curve were plotted (log C vs t). Two compartment open model was applied to estimate the kinetic parameters as t(1/2) beta e beta. A model independent calculation was applied to estimate the kinetic parameters as AUCT, CIT and Vd. Initially, parametric and nonparametric tests were applied. Due to the high dispositional variability, nonparametric statistics (Wilcoxon's test) was applied for analysis of results obtained. Based on data obtained in the present study the authors suggest linear pharmacokinetics where Cmax AUCT showed proportional increases with the dose administered, remaining unchanged the Kinetic parameters as t(1/2) B,B, CIT and Vd.

[Reduction mammoplasty with shortened scars: surgical technique]

Reduction mammaplasty is nowadays one of the most frequently performed plastic surgeries. The main purpose is the reduction of the volume of breasts, but the resulting scars can jeopardize the result of the operation. The Division of Plastic Surgery follows the modern tendency of reducing the length of the incisions and thus the resulting scars. A technique that incorporates this principle was developed with good results. The technique is simple enough to be used in a training program.

[The correction of cryptotia with tissue expanders]

Cryptotia is a congenital abnormality represented by the absence of the retroauricular sulcus in its superior portion. As the physiopathology of the problem involves the lack of skin tissue in the superior part of the ear sulcus, Mulliken suggested for the first time in 1988, the use of skin expanders as a method to obtain the extra skin necessary to correct this deformity. We bring forward our experience in the use of skin expanders in the treatment of three patients with cryptotia, bilateral in one of them. The technical aspects of the operations as well as the types of expanders used are described in detail. In all cases the correction of the cartilagenous deformities, freeing of the superior pole of the ear and redefinition of the retroauricular sulcus were performed. There were no significant complications. There was no change of the initial good results after a two years follow-up.

[The use of MPG in preventing the post-reperfusion injury of an epigastric island flap: an experimental study in rats]

The objective of this work was to study the protective effects of the free radical scavenger N2-mercaptopropionylglycine used in a rat model of reperfusion of epigastric island flaps submitted to transient occlusion of their vascular pedicles. In one group the epigastic vein of the flap was occluded for 5 hours. In the second group the epigastric artery was occluded for 21 hours and in the third group both the epigastric vein and artery were occluded for 8 hours. The scavenger or equivalent volume of saline solution was injected 10 minutes before the vascular occlusion and 10 minutes before declamping. The flap viability was assessed on the seventh day after flap reperfusion. In the three types of vascular occlusion a significant, and differential, increase of the areas of flap survival was observed. The protective effect of N2-mercaptopropionylglycine in reperfusion injuries was demonstrated.

Abdominoplasty combined with other intraabdominal procedures

One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.

Soft-tissue expansion in lower extremity reconstruction

Soft-tissue expansion in the lower extremities is typically well tolerated. The more proximal one is--that is, the closer to the thigh and buttocks--the easier and less complication prone the expansion will be. It is another valuable technique for resurfacing the lower extremity and for reconstructing defects in contour and in skin character. There are limitations to this technique, which generally is most useful in late reconstructions. Intraoperative expansion has no place in lower extremity reconstruction. Soft-tissue expansion may be limited by an unsuitable geometry or the sheer size of defects. It should not be used next to open wounds. Soft-tissue expansion offers significant advantage in that the coverage of a defect will be replaced with tissue like that lost. Seldom does one see necrosis of advanced flaps, so that there is little risk of tissue loss in using this modality. There is an excellent vascularity to the flaps and an excellent character to the skin. In addition, in this cost-conscious era, soft-tissue expansion is quite cost effective, and in many cases the procedures can be conducted on an outpatient basis with a minimum of hospitalization, if any. With care to select patients properly, design carefully, and conduct expansion in a leisurely fashion, soft-tissue expansion offers a valuable means of reconstructing both large and small lower extremity defects.

[Use of posterior interosseus artery flap in the repair of forearm and hand]

The posterior interosseous vessels give a significant contribution to the fascial plexus which supplies the skin of the forearm. This vascular arrangement forms the basis for an island fasciocutaneous flap which can be based either proximally or distally. Its principal advantage is that it is a thin flap with excellent circulation and that the donor area can be closed primarily. The design and usage of an island fasciocutaneous flap with possibility of expansion is also described.

[Use of tissue expanders on the scalp]

Tissue expanders have emerged recently as a new option for the treatment of alopecia. The method consists in expanding the scalp beyond the defective area. In this way, some disadvantages like the alterations in the donor area and low density of hair follicles, that may result from other techniques, are avoided. We present our experience with tissue expanders in the treatment of 32 patients with alopecia. The extent of these areas varied from 30 to 150 cm2, and the causes were: burn sequels in 12 patients; trauma sequels in ten; tumoral resections in ten; giant nevus pilosus in four and baldness (male standard) in two patients. The resection of the area with alopecia and the replacement by normal adjacent tissue was possible without any complications in all cases. However some disadvantages were observed. They included the necessity for a second surgical procedure because of marked deformity of the cephalic segment.

The use of tissue expanders for induction of facial skeletal growth

We present a case of successful orbital expansion with a tissue expander in 1 patient. This method will be valuable in preventing the facial deformities of anophthalmia and microphthalmia. The method was successful from a technical standpoint because of scleral investment of the expander and because of relative fixation of the expander by passage of the filling tube through the lateral orbital wall. The early experience of this patient confirms our expectations of successful orbital expansion based on the natural history of patients with orbital tumors or congenital glaucoma and on the experimental work of other investigators.

[Extensive trauma of the external ear: surgical management]

Fifty nine patients with extensive traumatisms of the external ear, including 3 total amputations, 10 partial amputations with maintenance of reduced pedicle and 46 extensive lesions without further vascularization, have been attended in the Emergency Unit of Hospital das Clinicas at University of São Paulo Medical School from 1979 to 1989. Surgical behaviors performed in each case are described and explained in detail. The main purpose of the study was to show the outliving possibilities of the ear even in serious traumas and to emphasize the need of immediate repair of the ear in order to obtain a satisfactory result.

[Usefulness of seat belts in the prevention of facial fractures]

In the first quarter of 1985, the use of the seat belts in every car was compulsory as disposed by law and it was discontinued afterwards. The authors correlate the number and type of facial fractures in patients admitted to the Emergency unit of the Hospital das Clínicas of University of São Paulo Medical School, during the first quarter of 1984, 1985 and 1986. A significant decrease of the number of cases and the severity of the facial fractures during the 1985 period was observed and, more important, a decrease was noted on the proportion of the nasal and fronto-orbital fractures among the overall number of fractures of the face. There was thus a significant relationship between the use of belts and the number and severity of the facial fractures.

[Use of the gracilis muscle in reconstructing the perineum]

Ten patients had their vulvar and perineal areas reconstructed using musculocutaneous flaps of the gracilis muscle. Seven patients had extensive resections done for skin carcinomas, two due to traumas and one due to a sequel of Fournier's Syndrome. Reconstruction in tumor cases were performed primarily and the other secondarily. The skin island measured 12 x 8 centimeters and the muscle was taken entirely. The results were satisfactory in all cases. The muscle survived completely, but there was partial skin island loss in 8 instances. In 3 of those cases, there was need for a revision of the flap and skin grafting. The authors concluded that there is always a risk to take the skin island together with the gracilis muscle and the use of the isolated muscle with skin grafting should be considered im most cases.

[Construction of the vagina by a non-surgical method]

The authors have performed in 150 cases the surgical reconstruction of the vagina using the McIndoe's technique. Since 1986 they are using the non-surgical technique devised by Frank in 1940. As a modification of the method, cylindric molds of acrilic with diameters varying between 1.5 and 3.0 cm have been used. Ten cases of congenital absence of the vagina and 12 intersex cases identified as belonging to the female sex, were treated by this progressive dilatation method. The results, were good and no complications occurred. The long-term follow-up has shown a stable and functional vagina. The main advantagens of the method are the simplicity and the low morbidity.