Botulinum A exotoxin for the management of platysma bands.

Injections of botulinum A exotoxin are successfully used to treat neuromuscular disorders and to improve hyperkinetic muscles and dynamic rhytids of the upper face. Using these principles, we extended its use to the treatment of the aging neck (hypertrophic platysma muscle bands). A classification system (I to IV) based on horizontal neck rhytids, platysma bands, and skin laxity was devised to categorize the degree of deformity and serve as a guideline for suggested dosages of botulinum. The results correlated with the degree of age-related neck degeneration. Type II (mild horizontal neck rhytids; thin, mild platysma muscle flaccidity; and mild skin laxity) and III (moderate horizontal neck rhytids; thick, moderate platysma muscle flaccidity; and moderate skin laxity) patients were the most satisfied, followed closely by types I and IV. A total of 1500 patients were treated by three independent practices. The majority of them achieved good-to-excellent results, as evaluated by both the physician and patient. The degree of muscle flaccidity and hypertrophy were the factors that most influenced success rates, not the anatomic variations in muscle configuration.

Cosmetic use of botulinum A exotoxin for the aging neck.

BACKGROUND: The use of botulinum toxin for facial rhytides has become more popular. In the past, plastic surgery was the only choice for rejuvenation of the aging neck. We discuss the cosmetic use of botulinum toxin for the rejuvenation of the neck and review the anatomy. OBJECTIVES: We will review the four age-related neck degeneration categories and discuss how to inject botulinum A exotoxin into the platysmal neck bands. RESULTS: We will discuss how botulinum can tighten neck jowls, eliminate horizontal neck rhytides, and improve skin laxity. CONCLUSION: Botulinum A exotoxin is a safe, effective, alternative treatment for rejuvenation of the aging neck and lower face. Patients are uniformly satisfied and complications are minimal.

Subcutaneous pheohyphomycotic cyst from a traumatic injury: reactivation after thirty-five years.

Pheohyphomycoses are an uncommon diverse group of dematiaceous fungi present in soil and plant material and are potential pathogens. We report the case of a 45-year-old white Hispanic woman who presented with a hard round cyst on the dorsum of her right foot caused by a traumatic implantation of a piece of wood thirty-five years earlier. The cyst was surgically excised and the patient empirically treated with a two-month course of oral itraconazole. To our knowledge, this represents a case of the longest-lived asymptomatic pheohyphomycotic cyst in an immunocompetent person ever reported. The clinical manifestations, treatment options, and disease course are reviewed.

Infection with methicillin-resistant Staphylococcus aureus after carbon dioxide resurfacing of the face. Successful treatment with minocycline, rifampin, and mupiricin ointment.

BACKGROUND: The incidence of cutaneous bacterial infection after carbon dioxide (CO2 laser resurfacing is increasing. Patients with staphylococcal colonization of their anterior nares may be at greater risk for postoperative cutaneous colonization and/or infection, which can potentially cause scarring. OBJECTIVE: We present a case report of methicillin-resistant Staphylococcus aureus secondary infection of the skin after CO2 laser resurfacing. We discuss the possible etiologies of this patient's infection, her postoperative management, and preoperative suggestions for possibly preventing infection. METHODS: A 49-year-old woman was treated with CO2 laser resurfacing for moderate actinic damage and facial rhytides. She developed a cutaneous infection with methicillin-resistant S. aureus, which caused diffuse linear scarring on her cheeks and upper lip. RESULTS: The patient was successfully treated with oral minocycline, rifampin, and topical mupiricin ointment to her cutaneous erosions. CONCLUSIONS: We propose that it would be helpful for patients undergoing CO2 laser resurfacing to have their nares cultured to see if they are staphylococcal carriers. If a patient is found to be a carrier, mupiricin ointment can be used preoperatively treat to the nares, to help decrease the risk of infection of the skin from this potential source.

Cutaneous disseminated histoplasmosis in AIDS patients in south Florida.

BACKGROUND: Histoplasma capsulatum is a dimorphic pathogenic fungus endemic to the Mississippi and Ohio river valleys. In the immunocompetent it causes a self-limited disease, but in the immunocompromised may lead to disseminated disease (disseminated histoplasmosis (DH)). It is one of the opportunistic infections which defines the acquired immunodeficiency syndrome (AIDS) and is rarely encountered outside endemic regions. METHODS: Clinical, laboratory, and histologic information concerning seven patients with DH and AIDS in South Florida was recorded. RESULTS: We report seven cases of DH with mucocutaneous lesions in patients infected with the human immunodeficiency virus (HIV). All patients had markedly depressed CD4 counts of less than 40 cells/mm3, and only two had traveled to endemic areas. Two out of the seven patients were diagnosed with HIV/AIDS at the time DH was identified. All of our patients had mucocutaneous lesions at the time of diagnosis, which clinically presented as a generalized papular eruption, ulcers, and erythematous scaly plaques. CONCLUSIONS: Even in non-endemic regions, HIV-positive patients presenting with fever, chills, weight loss, hepatosplenomegaly, anemia, cough, lymphadenopathy, and mucocutaneous lesions should have an early skin biopsy specimen taken for mycologic tissue culture and histopathologic evaluation for disseminated fungal infections.

Sweat gland carcinoma with metastases to the skin: response to 5-fluorouracil chemotherapy.

A 68-year-old white man presented to the inpatient service at Columbia-Presbyterian Hospital with a chief complaint of a progressively enlarging tumor of the right infraorbital region for many years and multiple, pink papulonodules on his head, neck, and trunk. A biopsy specimen of the right infraorbital and back lesions demonstrated an infiltrating adenocarcinoma with prominent signet ring cells, and small lumen formation. Results of an extensive work-up revealed bone marrow metastases and no evidence of a primary malignancy. We present a case of primary sweat gland carcinoma with metastases to the skin based upon history, clinical presentation, results of physical examination, histopathologic examination, immunohistochemical studies, and response to 5-fluorouracil chemotherapy. Due to the rarity of the tumor, the diagnosis is usually not made until the tumor(s) is invasive. An excellent response to systemic chemotherapy with 5-fluorouracil in metastatic sweat gland carcinoma was noted in this case.

Infantile myofibromatosis: a case report.

A male infant had three nodules on the left cheek, right forearm, and right neck. Biopsy specimen revealed infantile myofibromatosis (IM). Further evaluation revealed a solitary pulmonary nodule in the right middle lobe located far from mediastinal structures, which had no evidence of tumor enlargement on follow-up tomographic scan. Immunoperoxidase studies were negative for desmin and positive for actin. This is a potentially life-threatening multiorgan system disease; however, if lesions are limited mainly to the skin and soft tissues, the prognosis becomes more favorable. Although many reports suggest spontaneous and complete healing of the cutaneous lesions, our patient had profound atrophy at lesion sites as resolution occurred.