Two Cases of Autoimmune Syndrome Induced by Adjuvants (ASIA): A Multifaceted Condition Calling for a Multidisciplinary Approach

Silicone implants have been used for cosmetic enhancement and reconstructive purposes for over 60 years. Despite assiduous efforts to ensure safety, there is continuous evidence that they are not as biologically inert as previously postulated. We present two cases of autoimmune syndrome induced by adjuvants (ASIA) in Hispanic women. The first patient developed biopsy-proven immune-mediated necrotizing myopathy that was successfully treated with the combination of silicone explantation along with immunosuppressive therapy. Findings after implant removal demonstrated rupture and leakage of silicone from gluteal implants. The second patient developed autoimmune hemolytic anemia in the setting of a ruptured silicone breast implant. Similarly, the patient was treated with corticosteroids followed by breast implant removal with complete resolution of symptoms. The successful treatment of these patients was achieved by collaboration between rheumatology and plastic surgery, which emphasizes the need for a multidisciplinary approach in the diagnosis and management of patients with ASIA

Two Cases of Autoimmune Syndrome Induced by Adjuvants (ASIA): A Multifaceted Condition Calling for a Multidisciplinary Approach

Silicone implants have been used for cosmetic enhancement and reconstructive purposes for over 60 years. Despite assiduous efforts to ensure safety, there is continuous evidence that they are not as biologically inert as previously postulated. We present two cases of autoimmune syndrome induced by adjuvants (ASIA) in Hispanic women. The first patient developed biopsy-proven immune-mediated necrotizing myopathy that was successfully treated with the combination of silicone explantation along with immunosuppressive therapy. Findings after implant removal demonstrated rupture and leakage of silicone from gluteal implants. The second patient developed autoimmune hemolytic anemia in the setting of a ruptured silicone breast implant. Similarly, the patient was treated with corticosteroids followed by breast implant removal with complete resolution of symptoms. The successful treatment of these patients was achieved by collaboration between rheumatology and plastic surgery, which emphasizes the need for a multidisciplinary approach in the diagnosis and management of patients with ASIA

Deeper Seated Than Skin Deep: Report of a Rare Case of Follicular Occlusion Tetrad and a Literature Review

Follicular occlusion tetrad (FOT) is a clinical syndrome consisting of hidradenitis suppurativa (HS), acne conglobata (AC), dissecting cellulitis of the scalp (DCS), and pilonidal cyst (PC). These entities typically occur independently, but occasionally present simultaneously comprising FOT. The four components share similar pathophysiology affecting the apocrine glands, follicular hyperkeratinization being the hallmark of each entity.Understanding shared similarities of each disease is paramount for the treatment approach as the relapsing and chronic nature of this syndrome can be burdening to patients. We present the case of a 22- year-old obese Hispanic man with a history of tobacco use who presented with worsening skin lesions. The patient developed extensive facial cystic acne 5 years before presentation, followed by left axillary hidradenitis suppurativa lesions two years before the presentation and right axillary involvement one year after. Skin manifestations then expanded to include the lower back, gluteal and perineal areas. The patient was diagnosed with FOT and despite conservative medical management, his lesions failed to improve. He ultimately underwent multiple staged excisional debridement surgeries and skin grafts. Our case underlines the presence of a syndromic association of cutaneous lesions that share a common pathogenesis and emphasizes that this entity requires a multidisciplinary approach. New biologic therapies continue to emerge and may potentially prevent the need for surgical intervention and the burden associated with it

Modification of Current Techniques: Increasing Nipple Projection in Patients Receiving Nipple-Areolar Complex (NAC) Reconstruction

Breast cancer is the most common malignancy diagnosed in women aside from nonmelanoma skin cancer; 276,480 new cases of breast cancer are estimated to be diagnosed by the end of 2020.1 An estimated 76% of patients with stage III or IV breast cancer pursue mastectomy as part of their treatment.2 Recent breast reconstruction trends reveal an upsurge in the percentage of patients pursuing breast reconstruction following mastectomy recent studies reveal that 54-63% of women undergoing mastectomy decide to pursue breast reconstruction.3 Breast reconstruction is conventionally considered complete after the restoration of the Nipple-areolar complex (NAC), 71% of patients consider a breast to appear incomplete without NAC reconstruction. A lack of NAC reconstruction has been revealed to negatively impact a patients perception of self; NAC reconstruction can improve psychosocial well-being and aesthetic outcomes. Factors that affect NAC patient satisfaction include nipple and areolar shape, color, and nipple projection.4 Various autologous methods of reconstructing the NAC have previously been described; however, a barrier to successful NAC reconstruction has been loss of nipple projection over time. This study describes a modification of current nipple projection techniques that utilizes autologous de-epithelized rolled dermal tissue from previous or current surgical sites to maintain nipple projection. Perioperative dermal autografts were obtained from patients from areas of current incisions or previous scar formation. For instance, dermal autografts could be obtained from C-section scar revisions, liposuction incisions, or abdominoplasty incisions. Thus, by salvaging tissues that would have otherwise been discarded intraoperatively an autograft can be obtained without adding additional scarring. After determining the donor site, rectangular segments of skin approximately 2 x 8 cm were excised, de-epithelized, and defatted on each side. The inferior aspect of the anticipated nipple skin was then bluntly dissected approximately 40% of the expected circumference. A cavity was then created under the skin at the expected nipple location; the dermal graft was then placed inside the cavity to provide projection and volume to the nipple. This study provides a modification of current techniques for maintenance of nipple projection. This method reduces additional scarring, which could negatively impact patient satisfaction, and does not require the need for a prosthetic device. Overall this modification of technique improves cosmetic results to patients seeking NAC reconstruction

Description of a Novel Technique: Utilizing a De-Epithelialized Inferior Mastectomy Skin Flap to Preserve the Nipple-Areolar Complex in Patients with Stage II and III Breast Ptosis

Breast cancer is the most common malignancy diagnosed in women aside from non-melanoma skin cancer with 276,480 new cases of breast cancer estimated to be diagnosed by the end of 2020.1 Recently nipple sparing mastectomy (NSM) has become more common due to improved cosmesis and low rate of tumor recurrence.2 However, this can prove challenging in women with grade II or grade III breast ptosis due to difficulty with adequate positioning of the nipple-areolar complex (NAC) and its compromise of vascular supply. Staged mastectomy through a combination of autologous tissue flaps and surgical delay has been described in order to combat the risk of nipple necrosis.3-4 However, that technique provides a method of preserving the NAC that pertains to autologous based reconstructions, and the NAC is not positioned until the second stage. Our study describes a novel technique of utilizing a de-epithelialized inferior mastectomy skin flap to preserve the vascular supply to the NAC and allow adequate positioning during the first stage of an expander-based reconstruction on patients with grade II and grade III breast ptosis. _ To briefly describe the technique, a preoperative Wise pattern marking is placed as a guideline for the NSM. After completion of a standard mastectomy the remaining inferior mastectomy skin flap is deepithelialized. The viability of the inferior mastectomy skin flap and the NAC is then assessed with SPY Elite fluorescence imaging following intravascular administration of indocyanine green. If well perfused, the NAC is then marked and modified to the desired circumference and size. The wise pattern is closed over the either prepectoral or subpectoral expander based reconstruction. The preserved NAC is the externalized. Our study includes 9 consecutive patients performed from July 2019 to December 2019, with a total of 18 breasts included in the study. 89 percent of the salvaged NACs remained viable throughout the reconstruction, with only 1 NAC with postoperative partial NAC necrosis. This study provides a novel technique for preservation of the NAC in patients with grade II and grade III ptosis undergoing expander-based reconstruction after a wise pattern NSM