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.

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.

11. Blepharoplasty Early Presentation < 2 Weeks Post-op Delayed Presentation 2 - 5 Weeks Post-op Late Presentation > 5 Weeks Post-op

12. Blepharoplasty < 2 Weeks Streptococcus Staphalococcus aureus Group A B Hemolytic Strep. - Necrotizing fasicitis Hypersensitivity Reaction Early Presentation

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. Early presentation Facial Cellulitis – Staph Aureus Note the chemosis and lid eversion

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. 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. Delayed Presentation

18. Suture Granuloma Suture Material

19. Noncaseating granuloma Chalazion Cutaneous Sarcoidosis Mycobacterial infections Fortuitum Chelonae Abcesess Tumor Sebaceous Cell Basal Cell >5 Weeks Post-op Late Presentation Blepharoplasty

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. >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. >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. >5 Weeks Post-op Late Presentation Blepharoplasty 6 months – await lesion stabilization Final aesthetic excision or scar revision and lid stabilization

25. Incisional biopsy = Cutaneous Sarcoidosis +ACE -CXR Firm nodule

26. Responded to Multiple Oral Steroid Challenges

27. At 6 months lesions are stable

30. Lateral Retinacular Dehiscence = Canthoplasty

31. 2 month follow-up

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

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