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Autologous fat transfer–induced facial nodule
J AM ACAD DERMATOL
Letters e107
VOLUME 69, NUMBER 2
rapid recurrence of LABD upon repeated exposure to buprenorphine represent singular characteristics. Helene Pol,a Suzanne Devaux, MD,a Emilie Tournier, MD,b Francoise Fortenfant, MD,c and Carle Paul, PhDa Dermatology,a Anatomopathology,b and Immunologyc Departments, Paul Sabatier University, Toulouse, France Funding sources: None. Conflicts of interest: None declared.
Fig 1. Bullous lesions on axillary area.
Correspondence to: Suzanne Devaux, MD, Dermatology, Larrey Hospital, 24 chemin de Pouvourville, 31059 Toulouse cedex 9, France E-mail: [email protected] REFERENCES 1. Paul C, Wolkenstein P, Prost C, Caux F, Rostoker G, Heller M, et al. Drug-induced linear IgA disease: target antigens are heterogeneous. Br J Dermatol 1997;136:406-11. 2. Pellicano R, Caldarola G, Cozzani E, Parodi A. A case of linear immunoglobulin A bullous dermatosis in a patient exposed to sun and an analgesic. Clin Ther 2009;31:1987-90. http://dx.doi.org/10.1016/j.jaad.2013.02.006
Autologous fat transfereinduced facial nodule
Fig 2. Direct immunofluorescence of perilesional skin: deposition of IgA in linear pattern at basement membrane zone.
days.1 The readministration of the drug would then trigger a more rapid occurrence of LABD.1 To our knowledge, no dose-dependency has been described in the literature. For the patient described here, the skin eruption was clearly more widespread with 8 mg buprenorphine than with 2 mg. Buprenorphine is a partial agonist of receptors. A previous report of LABD occurred with an analgesic in a patient exposed to sun.2 Buprenorphine is a medication that can be prescribed as analgesic with low strength. But for our patient there was no sun exposure and eruption was not localized on sunexposed areas. Our case illustrates the importance of a precise medication history to rule out drug-induced LABD. The inhaled route, the dose-dependency, and the
To the Editor: Autologous fat transplantation has been used as a filler for facial enhancement, contouring, and facial reconstruction since the late 1800s. Common side effects include pain, bleeding, and infection; rare, yet serious side effects include pulmonary fat embolism, stroke, meningitis, and septic shock.1 We present another rare side effect: localized nodular calcification. A 76-year-old renal transplant patient with a history of melanoma and multiple nonmelanoma skin cancers presented with a 4-month history of a 4-cm firm, nontender subcutaneous mass in the left preauricular area. This appeared 17 years after autologous fat injection to minimize a depression associated with surgery for a salivary tumor (Fig 1). An incisional biopsy was performed to exclude metastatic cancer or a parotid tumor and revealed only calcification. Because of the continued concern for a parotid tumor or metastasis, fine-needle aspiration was also performed, showing similar findings. Computerized tomography revealed a 3.5-cm partially calcified heterogeneous mass. Treatment involved a left superficial parotidectomy, removal of the growing subcutaneous mass, and treatment of the secondary bacterial infection with intravenous antibiotics. The pathology demonstrated fibrosis, fat necrosis, dystrophic calcification,
J AM ACAD DERMATOL
e108 Letters
Fig 1. Localized nodular calcification: 4-cm firm, nontender subcutaneous nodule in left preauricular cheek.
and hemorrhage with hemosiderin deposition, without signs of malignancy (Fig 2). The patient healed well after surgery, and no recurrence was observed in the following 6 months. Autologous fat transplantation is a useful technique for enhancement and reconstruction. Although substantial research demonstrates its use in the breast, less evidence is available with regard to its use elsewhere.1 Aside from cosmetic uses, this technique is gaining popularity for treatment of congenital, traumatic, and postsurgical craniofacial volume defects.2 Autologous fat is a natural filler that can easily be removed from the thigh or abdomen through a small port with minimal risk of scarring and no risk of allergic reactions/rejection that are reported with other filler substances.3 Fat autografting of the breast commonly leads to the formation of nodules that can be necrotic and calcified. The risk is increased when larger amounts of fat are injected.3 This is often detected by mammography, a particularly significant finding because necrotic fat with calcifications can mimic malignancy. Ultrasound serves to distinguish these conditions.3 It is not surprising that injection of autologous fat in the face might produce similar necrotic, calcified nodules. The largest retrospective review of complications after autologous fat transplantation of the face was recently published.4 Of 1261 patients receiving fullface fat injections (injections into the forehead, cheeks, temples, and chin), 62 developed complications during a 19-month average follow-up period. There was an increased frequency of calcification/ fibrosis complications with each additional injection number (0 patients with calcifications/fibrosis after first injection, 29% of patients after the second injection, and 66% if patients had a third injection).4
AUGUST 2013
Fig 2. Localized dystrophic calcification: histopathology shows fat necrosis and dystrophic calcification without signs of malignancy. (Hematoxylin-eosin stain.)
To our knowledge, no cases of localized nodular calcification occurring so late after initial transplantation have been reported. This rare complication can mimic metastatic disease, as was the case in our patient. Biopsies, ultrasound imaging, and fineneedle aspirations are useful in evaluating these nodules, and excision is typically curative. Lindsey A. Brodell, MD, Alejandro A. Gru, MD, Bruce Haughey, MD, and Eva A. Hurst, MD Washington University School of Medicine, Barnes Jewish Hospital, Saint Louis, Missouri Funding sources: None. Conflicts of interest: None declared. Correspondence to: Eva A. Hurst, MD, Division of Dermatology, Department of Internal Medicine, Washington University, 969 N Mason Rd, Suite 200, St Louis, MO 63141 E-mail: [email protected] REFERENCES 1. Gutowski KA. ASPS Fat Graft Task Force. Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg 2009;124:272-80. 2. Wetterau M, Szpalski C, Hazen A, Warren SM. Autologous fat grafting and facial reconstruction. J Craniofac Surg 2012;23: 315-8. 3. Wang H, Jiang Y, Meng H, Zhu Q, Dai Q, Qi K. Sonographic identification of complications of cosmetic augmentation with autologous fat obtained by liposuction. Ann Plast Surg 2010;64:385-9. 4. Kim SM, Kim YS, Hong JW, Roh TS, Rah DK. An analysis of the experiences of 62 patients with moderate complications after full-face fat injection for augmentation. Plast Reconstr Surg 2012;129:1359-68. http://dx.doi.org/10.1016/j.jaad.2013.02.018
Letters e107
VOLUME 69, NUMBER 2
rapid recurrence of LABD upon repeated exposure to buprenorphine represent singular characteristics. Helene Pol,a Suzanne Devaux, MD,a Emilie Tournier, MD,b Francoise Fortenfant, MD,c and Carle Paul, PhDa Dermatology,a Anatomopathology,b and Immunologyc Departments, Paul Sabatier University, Toulouse, France Funding sources: None. Conflicts of interest: None declared.
Fig 1. Bullous lesions on axillary area.
Correspondence to: Suzanne Devaux, MD, Dermatology, Larrey Hospital, 24 chemin de Pouvourville, 31059 Toulouse cedex 9, France E-mail: [email protected] REFERENCES 1. Paul C, Wolkenstein P, Prost C, Caux F, Rostoker G, Heller M, et al. Drug-induced linear IgA disease: target antigens are heterogeneous. Br J Dermatol 1997;136:406-11. 2. Pellicano R, Caldarola G, Cozzani E, Parodi A. A case of linear immunoglobulin A bullous dermatosis in a patient exposed to sun and an analgesic. Clin Ther 2009;31:1987-90. http://dx.doi.org/10.1016/j.jaad.2013.02.006
Autologous fat transfereinduced facial nodule
Fig 2. Direct immunofluorescence of perilesional skin: deposition of IgA in linear pattern at basement membrane zone.
days.1 The readministration of the drug would then trigger a more rapid occurrence of LABD.1 To our knowledge, no dose-dependency has been described in the literature. For the patient described here, the skin eruption was clearly more widespread with 8 mg buprenorphine than with 2 mg. Buprenorphine is a partial agonist of receptors. A previous report of LABD occurred with an analgesic in a patient exposed to sun.2 Buprenorphine is a medication that can be prescribed as analgesic with low strength. But for our patient there was no sun exposure and eruption was not localized on sunexposed areas. Our case illustrates the importance of a precise medication history to rule out drug-induced LABD. The inhaled route, the dose-dependency, and the
To the Editor: Autologous fat transplantation has been used as a filler for facial enhancement, contouring, and facial reconstruction since the late 1800s. Common side effects include pain, bleeding, and infection; rare, yet serious side effects include pulmonary fat embolism, stroke, meningitis, and septic shock.1 We present another rare side effect: localized nodular calcification. A 76-year-old renal transplant patient with a history of melanoma and multiple nonmelanoma skin cancers presented with a 4-month history of a 4-cm firm, nontender subcutaneous mass in the left preauricular area. This appeared 17 years after autologous fat injection to minimize a depression associated with surgery for a salivary tumor (Fig 1). An incisional biopsy was performed to exclude metastatic cancer or a parotid tumor and revealed only calcification. Because of the continued concern for a parotid tumor or metastasis, fine-needle aspiration was also performed, showing similar findings. Computerized tomography revealed a 3.5-cm partially calcified heterogeneous mass. Treatment involved a left superficial parotidectomy, removal of the growing subcutaneous mass, and treatment of the secondary bacterial infection with intravenous antibiotics. The pathology demonstrated fibrosis, fat necrosis, dystrophic calcification,
J AM ACAD DERMATOL
e108 Letters
Fig 1. Localized nodular calcification: 4-cm firm, nontender subcutaneous nodule in left preauricular cheek.
and hemorrhage with hemosiderin deposition, without signs of malignancy (Fig 2). The patient healed well after surgery, and no recurrence was observed in the following 6 months. Autologous fat transplantation is a useful technique for enhancement and reconstruction. Although substantial research demonstrates its use in the breast, less evidence is available with regard to its use elsewhere.1 Aside from cosmetic uses, this technique is gaining popularity for treatment of congenital, traumatic, and postsurgical craniofacial volume defects.2 Autologous fat is a natural filler that can easily be removed from the thigh or abdomen through a small port with minimal risk of scarring and no risk of allergic reactions/rejection that are reported with other filler substances.3 Fat autografting of the breast commonly leads to the formation of nodules that can be necrotic and calcified. The risk is increased when larger amounts of fat are injected.3 This is often detected by mammography, a particularly significant finding because necrotic fat with calcifications can mimic malignancy. Ultrasound serves to distinguish these conditions.3 It is not surprising that injection of autologous fat in the face might produce similar necrotic, calcified nodules. The largest retrospective review of complications after autologous fat transplantation of the face was recently published.4 Of 1261 patients receiving fullface fat injections (injections into the forehead, cheeks, temples, and chin), 62 developed complications during a 19-month average follow-up period. There was an increased frequency of calcification/ fibrosis complications with each additional injection number (0 patients with calcifications/fibrosis after first injection, 29% of patients after the second injection, and 66% if patients had a third injection).4
AUGUST 2013
Fig 2. Localized dystrophic calcification: histopathology shows fat necrosis and dystrophic calcification without signs of malignancy. (Hematoxylin-eosin stain.)
To our knowledge, no cases of localized nodular calcification occurring so late after initial transplantation have been reported. This rare complication can mimic metastatic disease, as was the case in our patient. Biopsies, ultrasound imaging, and fineneedle aspirations are useful in evaluating these nodules, and excision is typically curative. Lindsey A. Brodell, MD, Alejandro A. Gru, MD, Bruce Haughey, MD, and Eva A. Hurst, MD Washington University School of Medicine, Barnes Jewish Hospital, Saint Louis, Missouri Funding sources: None. Conflicts of interest: None declared. Correspondence to: Eva A. Hurst, MD, Division of Dermatology, Department of Internal Medicine, Washington University, 969 N Mason Rd, Suite 200, St Louis, MO 63141 E-mail: [email protected] REFERENCES 1. Gutowski KA. ASPS Fat Graft Task Force. Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg 2009;124:272-80. 2. Wetterau M, Szpalski C, Hazen A, Warren SM. Autologous fat grafting and facial reconstruction. J Craniofac Surg 2012;23: 315-8. 3. Wang H, Jiang Y, Meng H, Zhu Q, Dai Q, Qi K. Sonographic identification of complications of cosmetic augmentation with autologous fat obtained by liposuction. Ann Plast Surg 2010;64:385-9. 4. Kim SM, Kim YS, Hong JW, Roh TS, Rah DK. An analysis of the experiences of 62 patients with moderate complications after full-face fat injection for augmentation. Plast Reconstr Surg 2012;129:1359-68. http://dx.doi.org/10.1016/j.jaad.2013.02.018