SURGERY—COSMETIC

P5992John H. Woodbury and his 19th century cosmetic surgery empire

Keith Denkler, MD, UCSF Division of Plastic Surgery, San Francisco, California,United States

Cosmetic facial surgeons need to know the name of Dr. John H. Woodbury, a 19thcentury dermatologic surgeon that pioneered facelifts, blepharoplasties, browlifts,and multiple other cosmetic surgeries decades before other cosmetic surgeons.Woodbury is only known for his trademarked soap (sold for $200,000 to Jergens in1903) that he heavily advertised. However, he also advertised multiple cosmeticprocedures in newspapers, magazines, and pamphlets, but did not publish in theacademic journals. Reviews of these lay articles and illustrations (see multiplefigures) show he correctly designed skin and soft tissue operations for effectivecosmetic surgery of the face.Woodbury’s work was performed decades before otherpioneers with credit such as Miller, Joseph, Hollander, Passot, and Noel. Woodbury’sstory is unknown as hewas considered a quack, and shut down by the authorities forcorporate advertising. His ‘‘dermatologic institutes’’ employed 23 physicians over 5states. Woodbury, a dermatologist, needs to be acknowledged as the originalcosmetic surgeon pioneer, and entrepreneur, since his life ended so tragically inbankruptcy and suicide.

APRIL 20

cial support: None identified.

Commer

P6191Postreconstruction dermatitis of the breast

Alyx Rosen, Memorial Sloan-Kettering Cancer Center, New York, NY, UnitedStates; Babak Mehrara, MD, Memorial Sloan-Kettering Cancer Center, New York,NY, United States; Carolyn Goh, MD, David Geffen School of Medicine at UCLA,Los Angeles, CA, United States; Mario Lacouture, MD, Memorial Sloan-KetteringCancer Center, New York, NY, United States; Patricia Myskowsi, MD, MemorialSloan-Kettering Cancer Center, New York, NY, United States; Peter Cordeiro, MD,Memorial Sloan-Kettering Cancer Center, New York, NY, United States

Background: Approximately one-third of women diagnosed with breast cancerundergo mastectomy with subsequent implant-based or autogenous tissue-basedreconstruction. Potential complications include infection, capsular contracture, andleak or rupture of an implant with necessity for explantation. Whereas surgicalcomplications have been well characterized, frequently occurring dermatologicevents, such as rash, are relatively poorly described.

Methods: A retrospective analysis of breast cancer patients referred to the derma-tology service for diagnosis and management of a rash postmastectomy andexpander or implant placement or transverse rectus abdominis myocutaneous(TRAM) flap reconstruction was performed. Parameters studied included recon-struction types (expanders, silicone or saline implants, or TRAM flap) time to rashonset, clinical presentation at the time of dermatologic evaluation, associatedsymptoms, results of microbiologic studies, management, and outcome.

Results: We describe 21 patients who developed a rash on the skin overlying a breastreconstruction. Average time to onset was 25.7 months after tissue expanderplacement or TRAM flap reconstruction. The predominant clinical presentations ofthe rash included asymptomatic maculopapules or scaly, erythematous patches andplaques. Five patients (20%) had cultures of the rash obtained, all of which werenegative. Skin biopsy was felt to be relatively contraindicated in areas of skintension, and was reserved for nonresponding eruptions. Treatment for all rashesincluded topical corticosteroids and topical antibiotics, which resulted in acomplete or partial response in all patients with documented follow-ups.

Conclusion: Our findings suggest that tension and postsurgical factors play a causalrole in this hitherto undescribed entity: ‘‘postreconstruction dermatitis of thebreast.’’ This is a manageable condition that developsweeks to years following breastreconstruction. Topical corticosteroids and antibiotics result in restoration of skinbarrier integrity and decreased secondary infection.

cial support: None identified.

Commer

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P6447Severe systemic reaction associated with skin microneedling therapy in 2sisters: A previously unrecognized potential for complications?

Penelope Pratsou, MBChB, University Hospitals Coventry and Warwickshire NHSTrust, Coventry, United Kingdom; Joanna Gach, MBChB, University HospitalsCoventry and Warwickshire NHS Trust, Coventry, United Kingdom

Skin microneedling creates microconduits through the epidermis, resulting inneocollagenesis and neovascularization in the papillary dermis, used to treat acnescars, stretch marks and for facial rejuvenation. Two sisters, aged 34 and 44 years,underwent facial skin microneedling by a trained practitioner in a criss-crossmanner, following skin cleansing and topical anesthetic cream application. Aseparate sealed single-use, presterilized, CE marked, FDA registered drum-shapedroller (192 stainless steel microneedles; 8 rows, 1.5 mm long, 0.25 mm wide) wasused on each woman. Both developed marked neck lymphadenopathy within 24hours of the procedure. In addition, the older sister experienced immediate intenselocalized erythema and prolonged pinpoint bleeding, malaise, and headache.Systemic antibiotic treatment was unhelpful. She deteriorated further in thefollowing 2 weeks, developing a florid erythematous papular rash on the face,with progression to the trunk and limbs and associated facial edema. Hospitalizationwith oral and topical corticosteroid treatment led to gradual improvement over 2weeks. Infective and autoimmune screens were negative. Incisional biopsy revealeda non-specific, chronic inflammatory infiltrate. Patch testing to British standardseries, topical anesthetic cream, aftercare products and sunblock used, showedreaction to nickel sulphate (D4++), already known to the patient. On manufacturerinquiry, the roller microneedles were found to contain up to 0.006% sulphur and 8%nickel bound to surgical grade stainless steel alloy. Skin microneedling is considereda safe alternative to more invasive cosmetic procedures, with no down time andminimal side effects of mild transient erythema and bruising. Rarer adverse effectshave been attributed to: nonsterilized devices or roller reuse (microbial infections);nickel-plated microneedles (allergic contact dermatitis); inexpensive metal micro-needles (needle breakage); enhanced needle penetration caused by microneedlelength [2 mm or excessive operator force (trauma). Low sulphur stainless steelalloys containing nickel are thought to pose little or no risk in short term contactwith nickel-sensitive individuals. To our knowledge, this is the first report of serioussystemic reaction to treatment with a CE marked, FDA registered microneedle rollerin 2 sisters, highlighting the need for caution in offering microneedling as a risk-freeoption in cosmetic practice.

cial support: None identified.

Commer

SURGERY—DERMATOLOGIC

P6998Comparative effectiveness of suction-curettage and onabotulinumtoxin-Ainjection for the treatment of primary focal axillary hyperhidrosis

Omer Ibrahim, MD, Cleveland Clinic Foundation, Cleveland, OH, United States;Dennis West, PhD, Northwestern University, Chicago, IL, United States; EmirVeledar, PhD, Emory University, School of Medicine, Atlanta, GA, United States;Lauren Becker, MD, Northwestern University, Chicago, IL, United States; MuradAlam, MD, Northwestern University, Chicago, IL, United States; Rohit Kakar, MD,Oakwood Hospital and Medical Center, Dearborn, MI, United States

Background: Primary hyperhidrosis is a common disorder that has a negative impacton quality of life. Of numerous treatment modalities, 2 that are well-known are SCand BTX-A injection.

Purpose: Effectiveness of SC and BTX-Awere compared for efficacy in the treatmentof PFAH.

Methods: Twenty subjects, 7 female, ranged from 19 to 50 years old, with a previousdiagnosis of bilateral axillary hyperhidrosis were enrolled at a single center. Thesesubjects were randomly assigned via random sequence generation to receive BTX-Ainjections in 1 axilla and SC to the contralateral axilla at baseline, and received thesecond treatment at 3 months follow-up. Also, at baseline and at 3-months follow-up,gravimetric sweat analysis was performed and patients also completed theHyperhidrosis Disease Severity Scale (HDSS). A follow-up phone interview with arepeat HDSS was conducted at 6 months.

Results: Sweat production decreased 72.1% (resting) and 73.8% (exercise) com-pared to suction curettage 60.4% (resting) and 58.8% (exercise) (P¼.29 and .10). Atthe 3-month visit for light sweaters (sweat rate less than groupmean) the rate¼ 7.99mg/min in the BTX-A arm compared to 13.3 mg/min in the SC arm (P ¼ .09). Forheavy sweaters (sweat rate less than groupmean) the rate¼ 20.5 mg/min comparedto SC¼ 30.98 mg/min (P¼.0025). Quality of life by HDSS demonstrated that BTX-Acompared to SC at 3 months decreased severity by 0.8 points (P¼.0002) and by 0.9points (P ¼ .0017) at 6 months.

Limitations: The small sample size and single center are limiting factors for this study.

Conclusions: Onabotulinumtoxin-A injections are nominally more effective thansuction-curettage in reducing sweat rates. BTX-A is markedly more effective than SCfor heavy sweaters. Quality of life improved more with BTX-A compared to SC asseen by decrease in the HDSS severity scale.

cial support: None identified.

Commer

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