Mixing of Injectable Fillers: A National Survey.

BACKGROUND: The mixing of hyaluronic acid or calcium hydroxylapatite fillers with normal saline, plain lidocaine, or lidocaine with epinephrine before injection is a familiar practice among dermatologists. However, the frequency of this practice and rationale behind it has not been well studied. OBJECTIVE: To better elucidate the clinical practice of mixing fillers with other solutions before injecting among dermatologists. METHODS: A survey was electronically distributed to members of the American Society for Dermatologic Surgery. RESULTS: Four hundred seventy-five dermatologists responded to the survey. Thirty-five percent of respondents mix fillers before injection. Solutions used were as follows: plain lidocaine (44%), lidocaine with epinephrine (36%), normal saline (30%), and sterile water (7%). Respondents mix filler for the following reasons: to decrease viscosity (40%), increase anesthesia (30%), decrease swelling (17%), and increase volume (13%). CONCLUSION: Despite the lack of evidence, more than one-third of dermatologists surveyed mix fillers with other solutions before injection. Plain lidocaine is most commonly used. The top reason for mixing fillers is to decrease viscosity and facilitate ease of injection. More scientific data are needed to support this practice and better understand the biophysical changes that occur when mixing fillers with other solutions.

Reconstruction of an Alar Defect With a Fusiform Nasolabial Turnover Flap With a Proximal, Superiorly Tapered Apex.

The nasolabial turnover flap was first described by Spear et al in 1987 for the coverage of full thickness defects of the lateral ala. It offered a single-stage repair that recreated the internal nasal lining, the external nasal valve, and the rounded contour of the ala without requiring a cartilage graft. A frequently encountered problem with the execution of Spear's original design is elevation of the ipsilateral commissure of the adjacent lip due to its broad proximal pedicle. Here, the authors describe a fusiform-type design with a proximal, superiorly tapered apex that relies on anteriorly coursing perforators from the underlying angular artery. The authors also review the inherent advantages and disadvantages of the flap itself and the unique situation where there is a skin cancer adjacent to the donor site.

Mass Spectrometry Imaging Can Distinguish on a Proteomic Level Between Proliferative Nodules Within a Benign Congenital Nevus and Malignant Melanoma.

Histopathological interpretation of proliferative nodules occurring in association with congenital melanocytic nevi can be very challenging due to their similarities with congenital malignant melanoma and malignant melanoma arising in association with congenital nevi. We hereby report a diagnostically challenging case of congenital melanocytic nevus with proliferative nodules and ulcerations, which was originally misdiagnosed as congenital malignant melanoma. Subsequent histopathological examination in consultation by one of the authors (R.L.) and mass spectrometry imaging analysis rendered a diagnosis of congenital melanocytic nevus with proliferative nodules. In this case, mass spectrometry imaging, a novel method capable of distinguishing benign from malignant melanocytic lesions on a proteomic level, was instrumental in making the diagnosis of a benign nevus. We emphasize the importance of this method as an ancillary tool in the diagnosis of difficult melanocytic lesions.

Cutaneous Mastocytosis With Atypical Mast Cells in a 7-Year-Old Girl.

Cutaneous mastocytosis is defined by the presence of mast cells within the skin in the absence of other criteria for the diagnosis of systemic mastocytosis. Mast cells are characterized by an abundant granular cytoplasm and a round to oval or spindle-shaped nuclei. The presence of mast cells with bilobed and multilobed nuclei in cutaneous mastocytosis is a rare phenomenon and has been rarely reported in the literature. To our knowledge, there are only 4 reported cases of cutaneous mastocytosis with atypical mast cells. We hereby report a case of urticaria pigmentosa in a 7-year-old female patient. The patient presented with asymptomatic skin lesions of several years duration over the neck and left scapular area. Histopathological examination revealed the presence of middermal perivascular infiltrates mainly composed of mast cells, few lymphocytes, and eosinophils. Most mast cells showed pleomorphic nuclei with bilobed and multilobed morphology that revealed a positive expression for CD117, tryptase, CD68, and Giemsa stains. Based on these findings the diagnosis of urticaria pigmentosa with atypical mast cells was made. Additional tests to rule out systemic involvement were performed. All values, including a tryptase level, were within normal limits. No changes were noted after 1-year follow-up.

Folliculocentric Lichen Sclerosus et Atrophicus in a 10-Year-Old Girl.

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory scarring disease with a predilection for the anogenital area; however, 15%-20% of LSA cases are extragenital. The folliculocentric variant is rarely reported and less well understood. The authors report a rare case of extragenital, folliculocentric LSA in a 10-year-old girl. The patient presented to the dermatology clinic for evaluation of an asymptomatic eruption of the arms and legs, with no vaginal or vulvar involvement. Physical examination revealed the presence of numerous 2-4 mm, mostly perifollicular, hypopigmented, slightly atrophic papules and plaques. Many of the lesions had a central keratotic plug. Cutaneous histopathological examination showed features of LSA. Based on clinical and histological findings, folliculocentric extragenital LSA was diagnosed.

Temporary henna tattoos and hypertrichosis: a case report and review of the literature.

BACKGROUND: Temporary black henna tattooing is highly popular among children and young adults in some regions. The unmonitored addition of different products to darken the color of pure henna has been the cause of many tattoo-associated dermatoses. OBSERVATION: Hypertrichosis secondary to henna pseudotattoo is a rare, newly recognized cutaneous manifestation. Only 4 case reports of henna tattooing causing localized hypertrichosis have been reported in the literature. We report a case of hypertrichosis and eczematous reaction to temporary henna tattoo. CONCLUSION: Hypertrichosis secondary to black henna is independent of the presence of contact dermatitis. The mechanism by which black henna induces hair growth remains unclear.

Drug-induced linear IgA bullous dermatosis simulating toxic epidermal necrolysis.

Linear IgA bullous dermatosis (LAD) is an autoimmune subepidermal blistering disorder. LAD may be either idiopathic or drug related; the most common drug being vancomycin. The clinical presentations of both idiopathic and drug-related LAD are variable and may mimic other blistering disorders. We report a case of a 76-year-old man known to have a renal cell carcinoma who presented a vancomycin-induced LAD that clinically mimicked toxic epidermal necrolysis (TEN).

Adalimumab-induced lichenoid drug eruption.

Tumor necrosis factor (TNF)-α inhibitors are being widely and increasingly used for the management of a spectrum of rheumatologic diseases that are refractory to conventional disease modifying anti-rheumatic drugs. Various cutaneous side effects have been reported after treatment with TNF-α inhibitors. We present a case report of a 26-year-old male patient who developed a lichenoid drug eruption few months after the initiation of adalimumab for the management of Crohn's disease. We also highlight the clinical and histopathologic differences between lichenoid drug eruptions and idiopathic lichen planus.