Pot Pouri: Fat grafting, common derm conditions

Question 2

List the advantages of using autologous fat as a filler

Answer 2

• Tissue properties
  
  • abundant and readily available
  • has angiogenic and vasculogenic properties
  • biocompatable
  • potential for integration
  • contains 100-1000x more pluripotent cells then bone marrow
  • permanent (after stabilization)
• Technical properties
  
  • ease of harvest
  • relatively (comparatively) inexpensive
  • does not require cell expansion

Question 3

Describe theories of fat survival

Answer 3

1. Host replacement: adipocytes are phagocytosed by histiocytes, form foam cells, that replace fat in location and volume
2. Cell survival: adipocytes that are revascularized will survive; those that are not revascularized are phagocytosed by histiocytes and resorbed

Question 4

Describe the phases of graft take.

Answer 4

• Like graft take: imbibition/inosculation/revascularization
• Imbibition wihtin first 3 days
  
  • extensive infiltration of inflammatory cells; no reaction of adipocytes
• Inosculation at 4 days
  
  • recipient and donor vessel connect antegrade
• Angiogenesis at 4++++ days
  
  • vessels connect bidirectional as adipocytes are revascularized
  • if not revascularized then fat degenerates
    
    • btwn day 4 - 60 absorption peaks
  • @ 1 yr remaining fat is stable

Question 5

list and briefly describe the options for autologous fat grafting

Answer 5

• macrograft
  
  • unaltered adipose tissue & stromal components, taken en bloc
  • used for dead space filler for small spaces (H&N, frontal sinus, etc)
  • disadv: unpredictable graft take/failure
• dermis-fat graft
  
  • near-full thickness dermis + variable (~ 2cm thick) underlying unaltered fat
  • augments small contour defects; interpositional & glide barrier (nerves, tendons & skin)
  • around 50% graft loss at 1 yr, risk of graft loss
• micrograft
  
  • adipose harvested with liposuction cannula (manual suction, suction-assisted, other) and therefore stroma is not captured
  • useage
    
    • volume:
      
      • small vol: cosmetic facial augmentation, penis
      • lg vol: breast, buttock augmentation
    • regeneration/reconstruction
      
      • sm vol: cleft lip/palate, scar recontouring, nipple reconstruction, VPI, non-healing ulcer/wound
      • lg vol: partial/total breast recon; radiated skin wounds

Question 6

Describe the coleman technique for fat transfer

Answer 6

1. Tumescence
   
   1. RL + 1:400,000 epi; 1:1 (superwet technique)
2. Blunt cannula, larger bore (3-4mm)
   
   1. if small volume, try to do manual (true coleman)
   2. if large volume, then suction-assisted
3. Lipoaspirate
   
   1. Centrifuge or sediement; wick the supernatent
4. injection
   
   1. transferred in 1-3mL aliquots in small tunnel (for small vol)
   2. use 18g+ needle/cannula
   3. inject as needle is withdrawn
   4. multiple passes; criss-cross
   5. all layers: deep, intramuscular, subfascial, subcutaneous

Question 7

what are the layers in a fat aspirate after it has been allowed to settle (+.- centrifuge)

Answer 7

1. oil (from ruptured adipocytes)
2. fat/adipocytes
3. blood, serum, water, infiltrate +/- pellet (if centrifuged)

Question 8

what are the processing methods for aspirated fat

Answer 8

• sedimentation
  
  • • wick away or decant the serum
• centrifuge
  
  • best is < 3000rpm for 3 min
• washing
  
  • w NS, D5W, RL, sterile H20
• Cotton gauze (telfa) rolling
• other: revolve

Question 9

what are complications of fat grafting

Answer 9

• resportion
• under/overcorrection
• contour irregularities
• change over time can be unpredictable/ w weight gain
• infection
• microcyst
• calcifications
• fat necrosis
• migration
• embolism

Question 10

what are current controversies regarding fat transfer to breast

Answer 10

• controversy regarding cancer detection and risk
• now ASPS / radiologic groups agree shouldn’t affect cancer detection; microcyst and microcalcifications from fat necrosis should be distinguisable from malignancy
• regarding cancer risk - still controversial
  
  • ASPS supports FG after mastectomy
  • controversial still after partial mastectomy (no direct position, say contra-indicated in DCIS)
  • no position on augmentation in breast w no history of breast ca

Question 11

describe some guiding principles when considering autologous fat transfer to breast

Answer 11

• ASASP/ASPS supports fat transfer after mastectomy, with/without previous breast recon, with/without previous XRT
  
  • note: can improve skin quality after XRT
  • low risks, low complications (greatest risk is unpredictabiltiy of resporption)
  • undertake rigourous surveillance
  • do not use after partial mastectomy & DCIS
• In France, there are some defined contraindications to various scenarios
  
  • Augmentation / benign breast disease contraindications:
    
    • unreasonable expectations (expects large vol augment)
    • High risk for malignancy (familial, histologic, genetic)
    • Insufficient reserve of fat
    • abnormal pre-op breast imaging
  • After partial mastectomy for pre/invasive Ca contraindications:
    
    • evidence of local recurrence (remission not achieved)
    • Not completed all components of prescribed/indicated treatment
    • incomplete resection\
    • mets
    • < 2 yrs since surgery
  • After total mastectomy for pre/invasive Ca contraindications
    
    • local recurrence
    • < 2 yrs since surgery when HIGH RISK for recurrence
    • mets
      *

Question 12

What is erythema multiforme

Answer 12

Def. Self-limiting immune-mediated condition characterized by

• target lesions on the extensor acral surfaces (duscky erythematous center, halo blanched surrounding)
• no epidermal detachment
• affects palms and soles

EM minor = no oral mucosa involvement/corneal involvement

EM major = mucosal involvement

Etiology: MAINLY infection 90% of cases, (bacterial or viral), other drug-related NSAIDS, sulfonamides, antiepilectics, antibiotics

Infection: CMV, mycoplasma

Diagnosis: biopsy to exclude other conditions

Tx: treat underlying condition, stop drug, supportive

Question 13

what is SJS/TENs?

Answer 13

• SJS-TENs is a non-autoimmune severe exfoliative disease, that affects only stratified squamous keratinocytes (not columnar, cuboidal)
• = extensive necrosis and epidermal detachment

Question 14

describe the pathophysiology of SJS/TENs

Answer 14

• complex interaction of genetic pre-disposition, environmental exposure and cell-mediated immune response
• CD8+T cells produce cytolytic proteins CD95+ Fas-Ligand and granulysin
• Fas-Ligand couples w. Fas Receptor on Keratinocyte, induces apoptosis
• Initiates shedding/exfoliation just above basement membrane

Question 15

how do you make the diagnosis of SJS/TEN?

Answer 15

• combination of clinical features and definitive diagnosis established with pathologic review (after biopsy)
• SJS/TEN differentiated by TBSA (< 10 = SJS; 10-30 = SJS/TEN overlap; >30 = TEN)
• classic prodrome / crescendo phase build-up to skin findings (erythema, papules, bullae +/- widespread involvement and Nikolsky’s sign + and > 2 sites of mucosal involvement
• biopsy shows absence of inflammatory infiltrate, cleave plane above BM, large sheets of necrotic keratinocytes, presence of CD8+T cells & macrophages in dermis

Question 16

what is the etiology of SJS/TENs?

Answer 16

• DRUGS > 50-80%
  
  • antibiotics: penicillins, sulfa, fungal
  • anticonvulsant: phenytoin, phenobarb, carbemazepine, valproate
  • antiinflammatory: ibuprofen, naproxen, allopurinol
• Infection: bacterial, viral (measles, herpes), fungal
• Immunosuppression: GVHD, BMT, lymphoma, leukemia
• Idiopathic

Question 17

how do you prognosticate TEN?

Answer 17

• SCORTEN
  
  • cancer
  • HR (high)
  • age
  • TBSA
  • bicarb (low)
  • urea (high)
  • glucose (high)

Question 18

how do you treat STS/TEN

Answer 18

• remove causative agent
• define diagnosis (biopsy) & transfer to burn unit
• ACLS/ABLS
• supportive care
  
  • airway & breathing (oral cavity, upper aerodigestive tract involvement –> secure airway & breathing)
  • circulation: no directed fluid resuscitation, follow usual measures (consider 1/2 parkland)
  • determination of TBSA
  • analgesia
  • management of mucosal surfaces
    
    • ophtho consult, conjunctival sweeping
    • feed assist (NG)
    • foley, rectal tube, perineal care
  • management of skin
    
    • derm consult
    • debride blsiters if partially deroofed - leave if intact
    • if early, cover w/ biobrane
    • if contaminated, use jelonet,acticoat or allograft * avoid Ag sulfadiazine
  • systemic medical management
    
    • no good evidence to support prophylactic antibiotics, steroid or IVIG/cyclosporin/cyclophosphamide (controversial); derm to decide

Question 19

what is long term sequellae of SJS/TEN

Answer 19

• Skin: hyperpigmentation is biggest issue, nail deformities, hyperhidrosis
• Ocular: cicatricial deformity/synechiae, photophobia, visual impairment, blindness,
• Resp: Long-term pulmonary dysfunction
• GI: esophageal stenosis

GU: urethral stricture, phimosis, vaginal synechia, vaginal stenosis

Question 20

how do you differentiate between SJS/TEN and erythroderma multiforme?

Answer 20

• clinically they differ:
  
  • EM prodrome is absent or mild and onset of rash is abrupt; whereas in SJS/TEN prodrome for 3-5 days prior to onsent of rash
  • EM rash is characteristic target sign, where SJS/TEN is erythema, papules then blisters and exfoliation, with charactristic Nikolsky sign
  • EM typically has no mucosal involvement (EM major can have 1 site of involvement, usually oral) whereas SJS/TEN requires > 2 sites for diagnosis (usually oral, ocular, GIT, GU, resp)
• biopsy will definitively discern between processes
  
  • EM shows +++ inflammatory infiltrates, and small areas of keratinocyte apoptosis and vacuoles, from partial to total epidermal thickness
  • SJS/TEN shows sheets of necrotic keratinocytes with cleavage plane above BM, presence of CD8+T cells and macs in dermis

Question 21

what are autoimmunue bullous disease?

Answer 21

• Pemphigus vulgaris
• Bullous pemphigoid
• Epidermolysis bullosa

Question 22

what is your differential diagnosis for SJS/TEN?

Answer 22

• blistering skin conditions:
  
  • EM
  • pemphigus vularis
  • bullous pemphigoid
  • epidermolysis bullosa
• Infectious blistering skin conditions
  
  • staph scalded skin syndrome
  • toxic shock syndrome
  • pustular psoriasis

Question 23

define bullous phemphigoid

Answer 23

Bullous pemphigoid is a chronic, inflammatory, subepidermal, blistering disease. No mucosal involvement. Tense blisters

IgG autoantibodies bind to the skin basement membrane

Tx: steroids and immunosuppression

Question 24

what is pemphigus vulgaris?

Answer 24

PV = autoimmune, intraepithelial, blistering disease affecting the skin and mucous membranes. Flaccid blisters

• mediated by circulating autoantibodies directed against keratinocyte cell surfaces. A potentially life-threatening disease if no immunosuppressive therapy
• onset rapid with mucosal ulceration as presenting symptom

Question 25

what is epidermolysis bullosa?

Answer 25

• Epidermolysis bullosa (EB) is a group of inherited bullous disorders characterized by blister formation in response to mechanical trauma.
• EB dysfunctional D-E jx and intraepidermal adhesion proteins
  
  • EBsimplex - cleavage within BM
  • EB junctional - cleavage at DEjx and lamina lucida
  • EB dystrophic - cleavage in dermis, sub lamina lucida

Question 26

what are extra-cutaneous manifestations of epidermolysis bullosa?

Answer 26

Extracutaneous manifestations:

• Mucosal surfaces
• Infection (sepsis),
• SCC (well diff, aggressive, unresponsive to Rx, high mets, death within 5 yrs of 1^st SCC),
• Melanoma (slight ­risk)
• Mitten deformity of hand

KEY is to promote wound healing, manage non-healing areas, prevent infection, diagnose cutaneous malignancy,

Question 27

what is acne?

Answer 27

• inflammation of the pilosebaceous unit,

Etiologies

• Androgens
  
  • increase response to DHT w release of FFA and sebum which blocks pores
• Bacteria
  
  • propionebacterium acnes
    
    • lives in pilosebaceous unit

Question 28

Is there any risk of cutaneous malignancy / malignant transformation associated w/ chronic acne?

Answer 28

rhinophyma associated w/ malignant transformation BCC in 15-30%

Question 29

list congenital disorders of premature aging? which disorders are presumed safe for elective surgery?

Answer 29

• cutis laxa - safe
• pseudoxanthoma elasticum - safe
• progeria - not recommended
• Ehler’s Danlos - not recommeded
• Elastoderma - not recommended

Question 30

Define and describe cutis laxa. Why is it safe to perform elective surgery?

Answer 30

• Cutis laxa is an inherited disorder whereby elastin loses its elastic recoil property due to degenerative changes in elastin
• There are three types; the autosomal dominant type has findings localized to elastin in dermis
• The autosomal recessive and x-linked types have localized and systemic findings, whereby elastin in other structures can be affected as well (GI, cardio, pulmonary etc)
• Elective surgery is safe because the normal processes of wound healing are not impaired.

Question 31

Define and describe pseudoxanthoma elasticum. Why is it safe or not safe to do elective surgery?

Answer 31

• pseudoxanthoma elasticum is a hereditary connective tissue disorder whereby the elastin fibres become mineralized, typically affecting the skin, vessels and eyes.
• elective surgery is not specifically contraindicated, but patients may have slower wound healing, hypertrophic or keloid scarring, and extrusion of calcinosis

Question 32

Define and describe Ehler’s Danlos. Describe why it is safe or not safe to do elective surgery

Answer 32

• Ehlers Danlos is a congenital, heritable disorder of collagen synthesis and structure, characterized by joint hypermobility, cutaneous fragility, and hyperextensibility
• There are over 10 different types, and the clinical manifestions within and between types can be quite variable.
• In general, the disorder affects to a different degree the skin and soft tissue, bone and vessels
• Elective surgery is typically avoided due to impaired wound healing, due to a probably fibroblast dysfunction and abnormal collagen

Question 33

Define and describe progeria. Describe why elective surgery is safe or not safe

Answer 33

• progeria is a rare congenital hereditory disorder that affects skin, MSK and vasculature that is characterized by features of accellerated aging, including atherosclerosis, loss of subcutaneous fat and muscle, skin atrophy, osteoporosis, arthritis, poor growth, and alopecia
• given the severe atherosclerosis and microangiopathy, wound healing is abnromal elective surgery is not indicated

Question 34

Describe which lasers you would choose to treat which pigments for tattoo removal.

Answer 34

§ QSR –> black, blue, green, brown (DON’T USE ON RED –WILL TURN BLACK)

§ Nd/YAG: good for black, red

§ QSA excellent for darker tattoos

§ Er-YAG: good for light-colours

§ CO2 laser: good for flesh-colours