Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Inflammatory and Infectious Lesions Following Blepharoplasty W. Thomas McClellan, M.D. John C. McCallum, B.A. Julius W. Fe...
<ul><li>No disclosures </li></ul>
ASAPS 2007 Data <ul><ul><li>240,763 Blepharoplasty </li></ul></ul><ul><ul><ul><ul><ul><li># 1 Liposuction </li></ul></ul><...
Complications and Considerations  we often discuss   <ul><li>Lid Malposition </li></ul><ul><ul><li>Globe / Cheek relations...
` <ul><li>Little guidance exists for management of infectious or inflammatory lesions following blepharoplasty </li></ul><...
Purpose <ul><li>Increase the awareness of post-operative infectious and inflammatory lesions </li></ul><ul><li>Attempt to ...
Methods <ul><li>Retrospective review of eyelid lesions appearing 3-6 weeks following blepharoplasty </li></ul><ul><li>2004...
Results <ul><li>16 patients identified </li></ul><ul><li>All were female </li></ul><ul><li>Follow-up ranged from 6 months ...
Results <ul><li>Foreign body (suture material) </li></ul><ul><li>5 Noncaeseating granuloma </li></ul><ul><li>  3 Chalazion...
Algorithm development  <ul><li>Utilizing Experience and Literature  </li></ul><ul><li>Categorize patient into three groups...
Blepharoplasty Early Presentation   < 2  Weeks Post-op Delayed Presentation   2 - 5  Weeks Post-op Late Presentation   > 5...
Blepharoplasty < 2  Weeks Streptococcus  Staphalococcus aureus Group A B Hemolytic Strep. - Necrotizing fasicitis Hypersen...
Blepharoplasty < 2  Weeks Early Presentation Diagnosis and Treatment I + D Routine Culture, Gram Stain of Fluid * Oral Ant...
Early presentation Facial Cellulitis – Staph Aureus Note the chemosis and lid eversion
2 - 5  Weeks Post-op Foreign body  -Suture material, Powder, Make-up Delayed Typical Infection  -Suture abscess Suture gra...
Diagnosis and Treatment Lesion Disruption -I &D, Incisional Biopsy Routine Culture, Gram Stain, AFB and Fungal of Fluid Ty...
Delayed Presentation
Suture Granuloma   Suture Material
Noncaseating granuloma Chalazion Cutaneous Sarcoidosis  Mycobacterial infections Fortuitum Chelonae Abcesess Tumor Sebaceo...
>5  Weeks Post-op Late Presentation Blepharoplasty Dx and Treatment Lesion Disruption or Incisional Biopsy Routine Culture...
>5  Weeks Post-op Late Presentation Blepharoplasty ( + ) Culture Multi-drug regimen including IV and PO Amikacin 7.5mg/kg ...
>5  Weeks Post-op Late Presentation Blepharoplasty ( + ) Pathology Chalazion  Intralesional Triamcinolone  40mg/ml  0.1ml ...
>5  Weeks Post-op Late Presentation Blepharoplasty 6 months  – await lesion stabilization Final aesthetic excision or scar...
 
Incisional biopsy = Cutaneous Sarcoidosis  +ACE  -CXR Firm nodule
Responded to Multiple Oral Steroid Challenges
At 6 months lesions are stable
 
 
Lateral Retinacular Dehiscence = Canthoplasty
2 month follow-up
Conclusion <ul><li>Inflammatory and infectious lesion can be challenging to differentiate and have diametrically opposed t...
Conclusion – Key Points <ul><li>Have a low threshold for aspiration and biopsy </li></ul><ul><li>Late presentation  </li><...
<ul><li>Thank you </li></ul>
 
 
 
(+) Culture Typical = treat with typical antibiotics Suspect mycobacterial Multi-drug regimen including IV and PO Amikacin...
(+) Culture Typical = treat with typical antibiotics Suspect mycobacterial Multi-drug regimen including IV and PO Amikacin...
Blepharoplasty (+) Culture Typical = treat with typical antibiotics Atypical = Suspect mycobacterial Multi-drug regimen in...
Blepharoplasty (+) Culture Typical = treat with typical antibiotics Atypical = Suspect mycobacterial Multi-drug regimen in...
Upcoming SlideShare
Loading in …5
×

Atypical Eyelid Infections Following Blepharoplasty

5,160 views

Published on

Here is the podium presentation I gave at the American Society of Aesthetic Plastic Surgery in San Diego 2008. It addresses atypical infections following blepharoplasty. Specifically a timeline, labs, and treatment.

Published in: Health & Medicine
  • Blepharoplasty in Tuscany, Italy: http://www.giuseppespinelli.it/chirurgia-estetica-maxillo-facciale/blefaroplastica.html
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Atypical Eyelid Infections Following Blepharoplasty

  1. 1. Inflammatory and Infectious Lesions Following Blepharoplasty W. Thomas McClellan, M.D. John C. McCallum, B.A. Julius W. Few, M.D. Clinton McCord, M.D. Foad Nahai, M.D. T. Roderick Hester, M.D. Mark A. Codner, M.D.
  2. 2. <ul><li>No disclosures </li></ul>
  3. 3. ASAPS 2007 Data <ul><ul><li>240,763 Blepharoplasty </li></ul></ul><ul><ul><ul><ul><ul><li># 1 Liposuction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li># 2 Brest Augmentation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li># 3 Blepharoplasty </li></ul></ul></ul></ul></ul><ul><ul><li>51% increase in last 10 years </li></ul></ul>
  4. 4. Complications and Considerations we often discuss <ul><li>Lid Malposition </li></ul><ul><ul><li>Globe / Cheek relationship </li></ul></ul><ul><ul><li>Spacer to posterior lamella </li></ul></ul><ul><ul><li>Midface recruitment </li></ul></ul><ul><li>Chemosis </li></ul><ul><li>Dry eyes </li></ul><ul><li>Orbicularis innervation + eyelid incisions </li></ul>
  5. 5. ` <ul><li>Little guidance exists for management of infectious or inflammatory lesions following blepharoplasty </li></ul><ul><li>Challenging treatment for physician </li></ul><ul><li>Frightening for the patient </li></ul>
  6. 6. Purpose <ul><li>Increase the awareness of post-operative infectious and inflammatory lesions </li></ul><ul><li>Attempt to categorize these lesions into groups to help guide diagnosis and treatment </li></ul><ul><li>Present our treatment algorithm </li></ul><ul><li>Provide patient examples </li></ul>
  7. 7. Methods <ul><li>Retrospective review of eyelid lesions appearing 3-6 weeks following blepharoplasty </li></ul><ul><li>2004-2007 </li></ul>
  8. 8. Results <ul><li>16 patients identified </li></ul><ul><li>All were female </li></ul><ul><li>Follow-up ranged from 6 months to 3 years </li></ul><ul><li>Excision, Histological analysis, and Culture were performed on all lesions </li></ul><ul><li>Treatment plan reviewed </li></ul>
  9. 9. Results <ul><li>Foreign body (suture material) </li></ul><ul><li>5 Noncaeseating granuloma </li></ul><ul><li> 3 Chalazion </li></ul><ul><li> 2 Cutaneous Sarcoidosis </li></ul><ul><li>2 Atypical mycobacterial infections </li></ul><ul><li>2 Epidermal Inclusion Cysts </li></ul><ul><li>1 Pyogenic Granuloma </li></ul>
  10. 10. Algorithm development <ul><li>Utilizing Experience and Literature </li></ul><ul><li>Categorize patient into three groups based on time of lesion presentation </li></ul>
  11. 11. Blepharoplasty Early Presentation < 2 Weeks Post-op Delayed Presentation 2 - 5 Weeks Post-op Late Presentation > 5 Weeks Post-op
  12. 12. Blepharoplasty < 2 Weeks Streptococcus Staphalococcus aureus Group A B Hemolytic Strep. - Necrotizing fasicitis Hypersensitivity Reaction Early Presentation
  13. 13. Blepharoplasty < 2 Weeks Early Presentation Diagnosis and Treatment I + D Routine Culture, Gram Stain of Fluid * Oral Antibiotics 7-10 days = Typical Pathogens Chemosis management if present -Patching, Tarsorhaphy, Conjunctiva incision +/- canthotomy = if edema/fluid cause vision loss Admit for Facial Cellulitis Rule out = Necrotizing fasciitis Re-evaluate frequently Antibiotic Regimens Superficial – Choice PO Cephalosporin Augmentin Clindamycin Facial Cellulitis – Combo IV Ampicillan/Sulbactam (Unasyn) Cefuroxime (Ceftin) Metronidazole (Flagyl) OR Clindamycin Ciprofloxacin (Cipro) Metronidazole (Flagyl) Failure to respond Vancomycin
  14. 14. Early presentation Facial Cellulitis – Staph Aureus Note the chemosis and lid eversion
  15. 15. 2 - 5 Weeks Post-op Foreign body -Suture material, Powder, Make-up Delayed Typical Infection -Suture abscess Suture granuloma Epidermoid cyst Pyogenic Granuloma -Typically lateral Delayed Presentation Blepharoplasty
  16. 16. Diagnosis and Treatment Lesion Disruption -I &D, Incisional Biopsy Routine Culture, Gram Stain, AFB and Fungal of Fluid Typical Oral antibiotics -now at risk for delayed typical infection Incisional biopsy sent -Routine Pathology - Polarized light Re-evaluate frequently based on patient -usually one week Achieve lesion stability -Steroid injection -Definitive excision Blepharoplasty 2 - 5 Weeks Post-op Delayed Presentation
  17. 17. Delayed Presentation
  18. 18. Suture Granuloma Suture Material
  19. 19. Noncaseating granuloma Chalazion Cutaneous Sarcoidosis Mycobacterial infections Fortuitum Chelonae Abcesess Tumor Sebaceous Cell Basal Cell >5 Weeks Post-op Late Presentation Blepharoplasty
  20. 20. >5 Weeks Post-op Late Presentation Blepharoplasty Dx and Treatment Lesion Disruption or Incisional Biopsy Routine Culture + Gram Stain +AFB + Fungal Atypical media and stains -Lowenstein Jensen Media at 30ºC 6wks - * Ziehl Neelsen Stain -Fluorescent auramine-O Stain Pathology -Tissue Identification + Polarized Light Typical Antibiotic Re-evaluate following initial cultures
  21. 21. >5 Weeks Post-op Late Presentation Blepharoplasty ( + ) Culture Multi-drug regimen including IV and PO Amikacin 7.5mg/kg IV bid – 8wks Imipenin 500 mg IV tid – 8 wks Clarithromycin 250mg PO bid – 12 wks Ciprofloxacin 500mg PO bid – 12wks Infectious disease consult Focus treatment on sensitivity results Weekly disruption of tissue Treatment for up to 12 weeks (-) Culture Review Pathology Consider Repeat Culture
  22. 22. >5 Weeks Post-op Late Presentation Blepharoplasty ( + ) Pathology Chalazion Intralesional Triamcinolone 40mg/ml 0.1ml x 2 inj. Oral steroid course – Medrol Dose Pack Incisional curettage Cutaneous Sarcoidosis Intralesional and oral steroid challenges Serum Angiotensin Converting Enzyme (ACE) CXR Rhematological referral Tumor Excision Frequent patient F/U and reassurance
  23. 23. >5 Weeks Post-op Late Presentation Blepharoplasty 6 months – await lesion stabilization Final aesthetic excision or scar revision and lid stabilization
  24. 25. Incisional biopsy = Cutaneous Sarcoidosis +ACE -CXR Firm nodule
  25. 26. Responded to Multiple Oral Steroid Challenges
  26. 27. At 6 months lesions are stable
  27. 30. Lateral Retinacular Dehiscence = Canthoplasty
  28. 31. 2 month follow-up
  29. 32. Conclusion <ul><li>Inflammatory and infectious lesion can be challenging to differentiate and have diametrically opposed treatments. </li></ul><ul><li>Proper diagnosis and categorization can lead to effective treatment. </li></ul>
  30. 33. Conclusion – Key Points <ul><li>Have a low threshold for aspiration and biopsy </li></ul><ul><li>Late presentation </li></ul><ul><ul><li>Mycobacterial until proven otherwise - ID Consultation </li></ul></ul><ul><ul><li>Cutaneous Sarcoidosis - Rheumatology referral </li></ul></ul><ul><li>Frequent patient visitation </li></ul><ul><li>Await lesion stabilization for definitive excision </li></ul><ul><li>Lid positioning </li></ul>
  31. 34. <ul><li>Thank you </li></ul>
  32. 38. (+) Culture Typical = treat with typical antibiotics Suspect mycobacterial Multi-drug regimen including IV and PO Amikacin 7.5mg/kg IV bid – 8wks Imipenin 500 mg IV tid – 8 wks Clarithromycin 250mg PO bid – 12 wks Ciprofloxacin 500mg PO bid – 12wks Infectious disease consult Focus treatment on sensitivity results Weekly disruption of tissue Treatment for up to 12 weeks Noncaseating granuloma Chalazion Cutaneous Sarcoidosis Mycobacterial infections Fortuitum Chelonae Abcesess Tumor Sebaceous Cell Basal Cell Dx and Treatment Lesion Disruption or Incisional Biopsy Routine Culture + Gram Stain +AFB + Fungal Atypical media and stains -Lowenstein Jensen Media at 30ºC 6wks - * Ziehl Neelsen Stain -Fluorescent auramine-O Stain Pathology -Tissue Identification + Polarized Light Typical Antibiotic Re-evaluate following initial cultures (-) Culture Review Pathology Consider Repeat Culture (+) Pathology Chalazion Intralesional Triamcinolone 40mg/ml 0.1ml x 2 inj. Oral steroid course – Medrol Dose Pack Incisional curettage Cutaneous Sarcoidosis Intralesional and oral steroid challenges Serum Angiotensin Converting Enzyme (ACE) CXR Rhematological referral Delayed excision Tumor Excision Frequent patient F/U and reassurance 6 months – await lesion stabilization Final aesthetic excision or scar revision and lid stabilization >5 Weeks Post-op Late Presentation Blepharoplasty
  33. 39. (+) Culture Typical = treat with typical antibiotics Suspect mycobacterial Multi-drug regimen including IV and PO Amikacin 7.5mg/kg IV bid – 8wks Imipenin 500 mg IV tid – 8 wks Clarithromycin 250mg PO bid – 12 wks Ciprofloxacin 500mg PO bid – 12wks Infectious disease consult Focus treatment on sensitivity results Weekly disruption of tissue Treatment for up to 12 weeks Noncaseating granuloma Chalazion Cutaneous Sarcoidosis Mycobacterial infections Fortuitum Chelonae Abcesess Tumor Sebaceous Cell Basal Cell Dx and Treatment Lesion Disruption or Incisional Biopsy Routine Culture + Gram Stain +AFB + Fungal Atypical media and stains -Lowenstein Jensen Media at 30ºC 6wks - * Ziehl Neelsen Stain -Fluorescent auramine-O Stain Pathology -Tissue Identification + Polarized Light Typical Antibiotic Re-evaluate following initial cultures (-) Culture Review Pathology Consider Repeat Culture (+) Pathology Chalazion Intralesional Triamcinolone 40mg/ml 0.1ml x 2 inj. Oral steroid course – Medrol Dose Pack Incisional curettage Cutaneous Sarcoidosis Intralesional and oral steroid challenges Serum Angiotensin Converting Enzyme (ACE) CXR Rhematological referral Delayed excision Tumor Excision Frequent patient F/U and reassurance 6 months – await lesion stabilization Final aesthetic excision or scar revision and lid stabilization >5 Weeks Post-op Late Presentation Blepharoplasty
  34. 40. Blepharoplasty (+) Culture Typical = treat with typical antibiotics Atypical = Suspect mycobacterial Multi-drug regimen including Clarithromycin + Amikacin Focus treatment on sensitivity results Infectious disease consult Treatment for up to 12 weeks < 2 Weeks Post-op 2 - 6 Weeks Post-op > 6 Weeks Post-op Atypical Infections Mycobacterial Viral Chalazion Cutaneous Sarcoidosis Tumor Delayed Typical Infections Pyogenic Granuloma Suture granuloma Foreign body Suture abscess Epidermoid cyst Typical Infection Group A Streptococcus - Necrotizing fasicitis Streptococcus pyogens Staphylococcus aureus Staph epi Hypersensitivity Reaction <ul><li>Treatment </li></ul><ul><li>Incision and Drainage </li></ul><ul><li>Routine Culture of Fluid </li></ul><ul><li>Oral Antibiotics 7-10 days </li></ul><ul><li>Choose one: </li></ul><ul><li>Ampicillin/Sulbactam </li></ul><ul><li>Cefuroxime </li></ul><ul><li>Clinadamycin </li></ul><ul><li>Ciprofloxin </li></ul><ul><li>+/- canthotomy </li></ul><ul><ul><li>if edema/fluid cause vision loss </li></ul></ul><ul><li>Eye lubrication </li></ul><ul><li>Rule out: </li></ul><ul><li>-Necrotising fasciitis </li></ul><ul><li>Admission </li></ul><ul><li>Debridement </li></ul><ul><li>Multi-IV Antibiotics </li></ul><ul><li>Hyperbaric Oxygen </li></ul><ul><li>*Caution in diabetic </li></ul><ul><li>Re-evaluate one week </li></ul>Treatment Incision and Drainage or Un-Roof Routine Culture and Routine Pathology -polarized light Oral antibiotics if warranted Re-evaluate in one week Steroid injection if stable Treatment Aspirate / Un-Roof the lesion Culture Routine + Gram Stain Atypical stains and media Oral Antibiotics for Typical coverage Re-evaluate one week (-) Culture Incisional biopsy R/o foreign body Polarized light Intra-lesional steroids (-) Pathology Improvement or Resolution then follow-up routine (+) Pathology or failure of intra-lesional steroids = oral steroid course W/U for Cutaneous Sarcoidosis ACE level CXR Rhematological referral F/u weekly – patient reassurance 6 months Final aesthetic excision and canthoplasty once lesion stable
  35. 41. Blepharoplasty (+) Culture Typical = treat with typical antibiotics Atypical = Suspect mycobacterial Multi-drug regimen including Clarithromycin + Amikacin Focus treatment on sensitivity results Infectious disease consult Treatment for up to 12 weeks Early Presentation < 2 Weeks Post-op Delayed Presentation 2 - 5 Weeks Post-op Late Presentation > 5 Weeks Post-op Mycobacterial Chalazion Cutaneous Sarcoidosis Tumor Delayed Typical Infections Pyogenic Granuloma Suture granuloma Foreign body Suture abcess Epidermoid cyst Streptococcus Staphalococcus aureus Group A B Hemolytic Strep. - Necrotising fasicitis Hypersensitivity Reaction <ul><li>Dx and Treatment </li></ul><ul><li>Aspirate or Incision + Drainage </li></ul><ul><li>Routine Culture of Fluid </li></ul><ul><li>Oral Antibiotics 7-10 days </li></ul><ul><li>Choose one: </li></ul><ul><li>Ampicillin/Sulbactam </li></ul><ul><li>Cefuroxime </li></ul><ul><li>Clinadamycin </li></ul><ul><li>Ciprofloxin </li></ul><ul><li>Re-evaluate one week </li></ul><ul><li>+/- canthotomy </li></ul><ul><ul><li>if edema/fluid cause vision loss </li></ul></ul><ul><li>Eye lubrication </li></ul><ul><li>Rule out: </li></ul><ul><li>-Necrotising fasciitis </li></ul><ul><li>Admission </li></ul><ul><li>Debridement </li></ul><ul><li>Multi-IV Antibiotics </li></ul><ul><li>Hyperbaric Oxygen </li></ul>Dx and Treatment Incision and Drainage or Un-Roof Routine Culture and Routine Pathology -polarized light Oral antibiotics if warranted Re-evaluate in one week Steroid injection/ Excision if stable Dx and Treatment Aspirate / Un-Roof the lesion Culture Routine + Gram Stain Atypical stains and media Oral Antibiotics for Typical coverage Re-evaluate one week (-) Culture Incisional biopsy R/o foreign body Polarized light Intra-lesional steroids (-) Pathology Improvement or Resolution then follow-up routine (+) Pathology or failure of intra-lesional steroids = oral steroid course W/U for Cutaneous Sarcoidosis ACE level CXR Rhematological referral F/u weekly – patient reassurance 6 months Final aesthetic excision and canthoplasty once lesion stable

×