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Acne vulgaris associated with a latissimus dorsi musculocutaneous island flap
British Journal ofPlastic Surgery (1986) 39,265-266 0 1986 The Trustees of British Association of Plastic Surgeons
Acne vulgaris associated with a latissimus dorsi musculocutaneous island flap R. H. MILNER
and T. A. PIGGOT
Department of Plastic Surgery, Newcastle General Hospital, Newcastle upon Tyne
Summary-A case is presented of the development of acne vulgaris in the skin island of a latissimus dorsi musculocutaneous flap used for breast reconstruction. The patient had acne scarring of the back but had had no active acne for twenty-five years. The latissimus dorsi musculocutaneous island flap is commonly used in breast reconstruction. The development of acne in association with skin flaps has not been described before and we speculate as to its cause. Case report A 47-year-old lady was admitted for breast reconstruction, having undergone a right simple mastectomy 9 years earlier for an infiltrating intraduct carcinoma. At that time axillary node involvement had been demonstrated and she was treated with Telecobalt external irradiation (4000rads over three weeks). A further primary appeared in the left breast 1 year later, and a left simple mastectomy was performed combined with an oophorectomy. She remained well over the next 8 years with no evidence of recurrence and was keen for breast reconstruction to be undertaken. She therefore underwent a right latissimus dorsi musculocutaneous flap reconstruction incorporating a 300 ml prosthesis. Two months after the operation she developed a papular rash confined to the skin island transposed from the back with the musculocutaneous flap. This papular rash had a pustular element with comedones and was typical of acne vulgaris (Fig. 1). The patient had suffered as a teenager from acne vulgaris predominantly affecting her back but had had no fresh acne lesions for 25 years. Examination revealed old acne scarring on the upper back but no evidence of any fresh lesions. Aqueous Povidone iodine solution (10%) was used to cleanse the skin pre-operatively and the donor site skin received no special treatment. In addition there were no post-operative applications or occlusive dressings used, which might have led to the development of acne. No difference in surface temperature could be demonstrated between the skin island, the skin over the opposite chest wall or the contralateral back skin. In addition, the flap appeared well vascularised. Microbiological cultures revealed no evidence of bacterial or candidal infection. She was placed on Erythromycin and Benzoyl Peroxide topically and over a period of several weeks her acne improved, but has not completely resolved.
Fig. 1 Figure l-Reconstructed right breast showing rash on skin of latissimus dorsi musculocutaneous flap, typical of acne.
Discussion The pathogenesis of acne is ill understood. In the patient described, the acne scarring was on the upper back, more marked laterally than medially, which is the typical distribution. The skin island was taken from this scarred area and an intrinsic property of that skin may be important. Relative ischaemia of the skin following its mobilisation on the muscle pedicle might be thought to have predisposed to the development of this patient’s acne. However, Williams et al. (1973) have shown experimentally that a reduction in the skin temperature of 1“C actually reduced the sebum excretion rate by 10%. In the case described there was no evidence of ischaemia or reduction in skin surface temperature of the musculocutaneous flap. 265
266
Friction due to tight fitting clothing has previously been recognised in association with acne in many situations (Frank, 1974). In the patient described it is possible that pressure from a brassiere encouraged the formation of acne; however it does not explain why it was restricted to the transposed flap. Acne has not previously been described in association with a surgical operation although Cunliffe and Cotterill (1975) described three cases of perioral acne following prolonged splinting of the teeth, which they attributed to immobility. An alteration in sebum production has been described on the face in association with lower motor neurone facial paralysis (Burton et al., 1971; Summerly et al., 1971). In addition, Thomas et al. (1985) have shown an increase in both the sebum excretion rate and the occurrence of acne below the neurological lesion in paraplegic patients. As there is no evidence to indicate direct neurological control of the sebaceous glands, they speculate that paraplegics have a larger follicular reservoir of sebum as a result of immobility and muscular paralysis. During the construction of the musculocutaneous flap the latissimus dorsi muscle was denervated and the skin island was therefore less mobile. This immobility may explain the development of acne, possibly by the same mechanism which affects paraplegic patients. It has been observed that there is an increase in keratinisation in the anaesthetic skin following division of the cutaneous nerves, although the mechanism is obscure (Petrone, 1969). It is possible that this keratinisation may create obstructiop of the pilosebaceous unit causing acne. No microbiological organisms were demonstrated in the patient studied. Bacteria are, however, frequently implicated in the development of acne, especially Cqvnbacterium Acnes and Staph-
BRITISH JOURNAL OF PLASTIC SURGERY
lococcus Epidermidis
(Marples, 1974). Although these organisms are not particularly virulent, any type of bacterial contamination is undesirable in the presence of a breast implant. It is therefore suggested that, if possible, areas of acne scarring should be avoided in the design of a latissimus dorsi musculocutaneous flap. References Burton, J. L., CunIiffe, W. J., Saunders, I. G. G. and Shuster, S. (1971). The effect of facial nerve paresis on sebum excretion. British Journal of Dermatology, 84, 135. CuuBffe, W. J. and Cotterill, J. A. (1975). The acnes: Clinical features: Pathogenesis and Treatment. (Chapter 2). London: W. B. Saunders Company Limited. Frank, S. (1974). Uncommon aspects of common acne. Cutis. 14,817. Marples, R. R. (1974). The microflora of the face and acne lesions. Journal OfInvestigative Dermatology. 62,326. Petrone, G. S. (1969). Accentuation of icthyosis vulgaris in denervated skin. Archives of Dermatology, 100,42. Summerly, R., Woadbury, S. and Boddie, H. G. (1971). The effect of facial nerve paresis on sebum excretion. (Letter). British Journal of Dermatology, 84,602.
Thomas, S. E., Conway, J., Ebling, F. J. G. and Harrington, C. I. (1985). Measurement of sebum excretion rate and skin temperature above and below the neurological lesion in paraplegic patients. British Journal of Dermatology, 112,569. Williams, M., Cunliffe, W. J., Williamson, B., Forster, R. A., Cotterill, J. A. and Edwards, J. C. (1973). The effect of local temperature changes on sebum excretion rate and forehead surface lipid composition. British Journal of Dermatology, 88, 257.
The Authors R. H. Miluer, BSc, DCH, FRCS, Senior House Officer, Department of Plastic Surgery, Newcastle General Hospital. T. A. Piggot, FRCS, TD, Consultant Plastic Surgeon, Newcastle General Hospital. Requests for reprints to: Mr T. A. Piggot, FRCS, TD, Department of Plastic Surgery, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, NE4 6BE.
Acne vulgaris associated with a latissimus dorsi musculocutaneous island flap R. H. MILNER
and T. A. PIGGOT
Department of Plastic Surgery, Newcastle General Hospital, Newcastle upon Tyne
Summary-A case is presented of the development of acne vulgaris in the skin island of a latissimus dorsi musculocutaneous flap used for breast reconstruction. The patient had acne scarring of the back but had had no active acne for twenty-five years. The latissimus dorsi musculocutaneous island flap is commonly used in breast reconstruction. The development of acne in association with skin flaps has not been described before and we speculate as to its cause. Case report A 47-year-old lady was admitted for breast reconstruction, having undergone a right simple mastectomy 9 years earlier for an infiltrating intraduct carcinoma. At that time axillary node involvement had been demonstrated and she was treated with Telecobalt external irradiation (4000rads over three weeks). A further primary appeared in the left breast 1 year later, and a left simple mastectomy was performed combined with an oophorectomy. She remained well over the next 8 years with no evidence of recurrence and was keen for breast reconstruction to be undertaken. She therefore underwent a right latissimus dorsi musculocutaneous flap reconstruction incorporating a 300 ml prosthesis. Two months after the operation she developed a papular rash confined to the skin island transposed from the back with the musculocutaneous flap. This papular rash had a pustular element with comedones and was typical of acne vulgaris (Fig. 1). The patient had suffered as a teenager from acne vulgaris predominantly affecting her back but had had no fresh acne lesions for 25 years. Examination revealed old acne scarring on the upper back but no evidence of any fresh lesions. Aqueous Povidone iodine solution (10%) was used to cleanse the skin pre-operatively and the donor site skin received no special treatment. In addition there were no post-operative applications or occlusive dressings used, which might have led to the development of acne. No difference in surface temperature could be demonstrated between the skin island, the skin over the opposite chest wall or the contralateral back skin. In addition, the flap appeared well vascularised. Microbiological cultures revealed no evidence of bacterial or candidal infection. She was placed on Erythromycin and Benzoyl Peroxide topically and over a period of several weeks her acne improved, but has not completely resolved.
Fig. 1 Figure l-Reconstructed right breast showing rash on skin of latissimus dorsi musculocutaneous flap, typical of acne.
Discussion The pathogenesis of acne is ill understood. In the patient described, the acne scarring was on the upper back, more marked laterally than medially, which is the typical distribution. The skin island was taken from this scarred area and an intrinsic property of that skin may be important. Relative ischaemia of the skin following its mobilisation on the muscle pedicle might be thought to have predisposed to the development of this patient’s acne. However, Williams et al. (1973) have shown experimentally that a reduction in the skin temperature of 1“C actually reduced the sebum excretion rate by 10%. In the case described there was no evidence of ischaemia or reduction in skin surface temperature of the musculocutaneous flap. 265
266
Friction due to tight fitting clothing has previously been recognised in association with acne in many situations (Frank, 1974). In the patient described it is possible that pressure from a brassiere encouraged the formation of acne; however it does not explain why it was restricted to the transposed flap. Acne has not previously been described in association with a surgical operation although Cunliffe and Cotterill (1975) described three cases of perioral acne following prolonged splinting of the teeth, which they attributed to immobility. An alteration in sebum production has been described on the face in association with lower motor neurone facial paralysis (Burton et al., 1971; Summerly et al., 1971). In addition, Thomas et al. (1985) have shown an increase in both the sebum excretion rate and the occurrence of acne below the neurological lesion in paraplegic patients. As there is no evidence to indicate direct neurological control of the sebaceous glands, they speculate that paraplegics have a larger follicular reservoir of sebum as a result of immobility and muscular paralysis. During the construction of the musculocutaneous flap the latissimus dorsi muscle was denervated and the skin island was therefore less mobile. This immobility may explain the development of acne, possibly by the same mechanism which affects paraplegic patients. It has been observed that there is an increase in keratinisation in the anaesthetic skin following division of the cutaneous nerves, although the mechanism is obscure (Petrone, 1969). It is possible that this keratinisation may create obstructiop of the pilosebaceous unit causing acne. No microbiological organisms were demonstrated in the patient studied. Bacteria are, however, frequently implicated in the development of acne, especially Cqvnbacterium Acnes and Staph-
BRITISH JOURNAL OF PLASTIC SURGERY
lococcus Epidermidis
(Marples, 1974). Although these organisms are not particularly virulent, any type of bacterial contamination is undesirable in the presence of a breast implant. It is therefore suggested that, if possible, areas of acne scarring should be avoided in the design of a latissimus dorsi musculocutaneous flap. References Burton, J. L., CunIiffe, W. J., Saunders, I. G. G. and Shuster, S. (1971). The effect of facial nerve paresis on sebum excretion. British Journal of Dermatology, 84, 135. CuuBffe, W. J. and Cotterill, J. A. (1975). The acnes: Clinical features: Pathogenesis and Treatment. (Chapter 2). London: W. B. Saunders Company Limited. Frank, S. (1974). Uncommon aspects of common acne. Cutis. 14,817. Marples, R. R. (1974). The microflora of the face and acne lesions. Journal OfInvestigative Dermatology. 62,326. Petrone, G. S. (1969). Accentuation of icthyosis vulgaris in denervated skin. Archives of Dermatology, 100,42. Summerly, R., Woadbury, S. and Boddie, H. G. (1971). The effect of facial nerve paresis on sebum excretion. (Letter). British Journal of Dermatology, 84,602.
Thomas, S. E., Conway, J., Ebling, F. J. G. and Harrington, C. I. (1985). Measurement of sebum excretion rate and skin temperature above and below the neurological lesion in paraplegic patients. British Journal of Dermatology, 112,569. Williams, M., Cunliffe, W. J., Williamson, B., Forster, R. A., Cotterill, J. A. and Edwards, J. C. (1973). The effect of local temperature changes on sebum excretion rate and forehead surface lipid composition. British Journal of Dermatology, 88, 257.
The Authors R. H. Miluer, BSc, DCH, FRCS, Senior House Officer, Department of Plastic Surgery, Newcastle General Hospital. T. A. Piggot, FRCS, TD, Consultant Plastic Surgeon, Newcastle General Hospital. Requests for reprints to: Mr T. A. Piggot, FRCS, TD, Department of Plastic Surgery, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, NE4 6BE.