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Sclerosing lipogranuloma (SLG) in children is a rare, benign disease of unknown etiology suspected to be due to abnormal fatty tissue reaction. A 13-year-old girl presented with progressively worsening back pain. Cross-sectional imaging identified a retroperitoneal mass compressing the left ureter as well as infrarenal inferior vena cava atresia with extensive venous collaterals and chronic partially occlusive thromboses of the iliac veins. Surgical biopsy was consistent with SLG and it resolved spontaneously. SLG is typically a disease of adulthood but may be seen in children. The association between inferior vena cava atresia with venous thrombosis and development of SLG has not been reported previously.

Ten years ago, a 57-year-old man fell into a full oilcan, penetrating the straight spout suborbital into the right frontal lobe (figure, A). Two years later, he developed symptomatic epilepsy. A cranial MRI showed extensive edema formation (figure, B) and pathologic contrast enhancement (figure, C). In a neurosurgical biopsy, multiple granulomas around small oil droplets appeared. Histopathologic analysis revealed a chronic meningoencephalitis with granulomas and giant cells congruent with a foreign body reaction (figure, D–F).

The cytopathology of a lipogranuloma of external origin is reported in the eyelid of a 32-year-old man excised 1 year following regional exposure to an explosion of hydraulic oil under high pressure. The foreign lipids were still present in chronic lipogranulomas with intercellular lipid-filled cysts surrounded by macrophages and giant cells containing intracellular lipid-filled vacuoles. These indicate efforts in storage and very slow digestion. Secondary fibrosis in the region of the lipogranuloma was an important associated process. In view of the widespread technical use of hydraulic oily fluids under high pressure, it is recommended that these fluids be biodegradable.

A type of sclerosing lipogranuloma of the male genitalia that is different from cases caused by injection or application of foreign bodies is reported in 4 patients. The characteristics of the disease are a symmetrical Y-shape of the granuloma, spontaneous regression, severe infiltration of eosinophils in the granuloma, eosinophilia of the peripheral blood and absence of any exogenous lipids by chemical analyses of the granuloma tissue. Ultrastructural study showed intracytoplasmic fat vacuoles of varied size in histiocytes and multinuclear giant cells. This is a new type of sclerosing lipogranuloma of the male genitalia and the pathogenesis of the disease is still unknown. (J. Urol., 140: 1021–1024, 1988)

The cosmetic injection of exogenous lipids and more recently of polydimethyl siloxane (injectable silicone) into the scrotum has been described since 1899. Sclerosing lipogranuloma and paraffinoma are terms applied to a complication of this practice in which the injected oils or silicone elicit a marked granulomatous reaction with prominent surrounding fibrosis. Although this complication has been described as a localized process occurring mainly in the scrotal area and regional lymph nodes, few studies have documented systemic manifestations. In this report we describe the autopsy findings of a 48-year-old man who had scrotal and systemic lipogranulomas from repeated self-administered injection of mineral oil. In addition, severe acute pulmonary edema resulted in sudden unexpected death. To our knowledge, this fatal complication of exogenous lipogranuloma has not been previously reported. Language: en

PURPOSE To assess the ophthalmologic complications after oculofacial plastic and esthetic surgeries, including their incidence and management. METHODS A retrospective study was performed on 110 patients who presented with ocular complications followed by oculofacial plastic and esthetic surgeries from January 2014 to December 2015. The incidence and management of complications after each surgery or procedure were analyzed. RESULTS For lower eyelid blepharoplasty, the common complications were chemosis and lower eyelid ectropion. There was also a case of canalicular laceration. Exposure keratitis and corneal abrasion were the most common complications after upper eyelid blepharoplasty. Chemosis frequently occurred after lateral cathoplasty, but other complications, such as ectropion, trichiasis, and lacrimal fistula, were also seen. Nasolacrimal duct obstruction occurred in some cases of orthognathic surgery, and was managed with endonasal dacryocystorhinostomy. Inflammatory lipogranuloma was a common complication after autologous fat transplantation. CONCLUSION Complications after oculofacial plastic and esthetic surgeries are not rare. Ophthalmologists must be aware of not only common complications but also rare and possibly serious conditions that may occur after such surgeries.

SPECIAL TOPIC Foreign Body Granulomas after All Injectable Dermal Fillers: Part 1. Possible Causes Foot Gottfried Lemperle, M.D., Ph.D. Nelly Gauthier-Hazan, M.D. Marianne Wolters, M.D. Marita Eisemann-Klein, M.D. Ute Zimmermann, M.D. David M. Duffy, M.D. San Diego and Los Angeles, Calif.; Paris, France; and Frankfurt am Main and Regensburg, Germany Summary Genuine granuloma formation following implantation of injectable dermal fillers is a rare complication, with incidences ranging from one in 100 patients (1 percent) to one in 5000 (0.02 percent). Foreign body granulomas occur several months to years after injection at all implantation sites at the same time. Without treatment, they may grow to the size of beans, remain virtually unchanged for some years, and then resolve spontaneously. Three clinical and histologic types of foreign body granulomas can be distinguished: 1. Cystic granulomas (synonyms: inflammatory, palisading, collagenolytic): these are caused mainly by injected biological gels such as collagens and hyaluronic acids. Their clinical signs are fluctuation (sterile abscess), extreme redness, and induration. Cystic granulomas are small and superficial, occur within the first year, and disappear spontaneously within another year. They are surrounded by a significant number of giant cells. 2. Edematous granulomas (synonym: lipogranuloma): these are caused by ar- tificial fluids such as silicone and polyacrylamides. They appear suddenly years after injection with extensive swelling and are surrounded and infil- trated by mononuclear and inflammatory cells. 3. Sclerosing granulomas (synonyms: sarcoidal and xanthelasmic): these are caused by particulate injectables composed of polymethylmethacrylate, poly- lactic acid, hydroxyethylmethacrylate, calcium-hydroxylapatite, or dextran microspheres. Sclerosing granulomas occur generally 6 months to 3 years after implantation and are visible, often bluish confined nodules. Histolog- ically, the implant is infiltrated by many macrophages and giant cells, fibro- blasts, and collagen fibers but few inflammatory cells. Permanent implants are not characterized by a higher rate of foreign body granuloma per se than temporary implants; however, their clinical appearance is more pronounced and their persistence longer if not treated adequately. (Plast. Reconstr. Surg. 123: 1, 2009.) T he increasing use of dermal filler substances in the treatment of wrinkles, the immense variety of new products, and the introduc- tion of new names without proper disclosure of their chemical contents make any overview difficult. 1 The general lack of reliable scientific description and trustworthy clinical data and pub- lications—positive or negative—meet a general lack of scientific interest and criticism on the part of the injecting physician. The sudden occurrence of a complication then leads to astonishment, neg- AQ: 1 From the Division of Plastic Surgery, University of Califor- nia, San Diego; private practice; the Department of Plastic Surgery, Caritas-Hospital St. Josef; the Private Institute of Histopathology; and the Department of Dermatology, Uni- versity of Southern California, Los Angeles. Received for publication June 14, 2007; accepted October 18, 2007. Copyright ©2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31818236d7 ligence, blame directed at the product, and often wrongful treatment of these troublesome compli- cations. The injectable dermal filler market has been undergoing a dynamic growth since the public became aware of nonsurgical approaches leading to wrinkle-free skin. Resorbable and nonresorb- able materials have been made injectable and are Disclosure: Gottfried Lemperle, M.D., Ph.D., is not an employee, consultant, agent, or representative of Artes Medical, Inc., which is the manufacturer of ArteFill. The opinions expressed in the article are not the opinions of Artes Medical, Inc. Dr. Lemperle is a shareholder of Artes Medical, Inc. None of the other authors has a financial interest in any of the products, devices, or drugs mentioned in this article. www.PRSJournal.com AQ: 1 rich3/zpr-prs/zpr-prs/zpr00609/zpr2421-09z xppws Sⴝ1 4/21/09 19:37 4/Color Figure(s): F1-13 Art: PRS200443 Input-nlm

We report a case of a 66-year-old woman who presented with multiple painless masses in both breasts. Prior bilateral biopsies were diagnosed as Rosai-Dorfman disease (Sinus Histiocytosis with Massive Lymphadenopathy). A recent lumpectomy specimen revealed a gray-white smooth cut surface with a discrete masslike lesion. The histopathology demonstrated a fibrotic breast parenchyma with foci of dense fibrosis and scattered inconspicuous breast epithelium surrounded by lymphocytes that formed aggregates and follicles with germinal centers. The inflammation was in a periductal, perilobular, and perivascular distribution. In addition, an exuberant inflammatory response with histiocytes and fibroblasts was present. This inflammatory response focally surrounded areas of fat necrosis and formed noncaseating granulomas with rare multinucleated giant cells. This process had infiltrative, ill-defined edges and involved the subcutaneous tissues. The overlying epidermis was normal. The final diagnosis was diabetic mastopathy with an exuberant lymphohistiocytic response. The differential diagnosis included Rosai-Dorfman disease, inflammatory myofibroblastic tumor, granulomatous mastitis, sclerosing lipogranulomatous response/sclerosing lipogranuloma, lupus panniculitis, and rheumatoid nodules. Immunohistochemical studies and flow cytometry confirmed the polyclonal nature of the lymphoid infiltrate. After the histologic evaluation, we inquired if the patient had a history of diabetes mellitus, and learned that she did have type 2 noninsulin-dependent diabetes mellitus. In conclusion, we report a case of diabetic mastopathy that presents with bilateral tumorlike masses and an unusual exuberant lymphohistiocytic response with granuloma formation. The pathologist may not be provided with a history of diabetes mellitus, but the characteristic fibrosis, lymphocytic ductitis/lobulitis, and sclerosing lobulitis with perilobular and perivascular lymphocytic infiltrates should provide clues for an accurate diagnosis, even when an exuberant and an unusual lymphohistiocytic response is present. A timely accurate diagnosis can help limit repeat surgeries in this vulnerable group of patients.

Background: Inhibitors of HIV-1 protease produce a rapid decrease in plasma HIV-1 RNA, with concomitant immune reconstitution. However, severe metabolic side effects together with a previously unseen form of lipodystrophy have been associated with long-term use of protease-inhibitor therapy. The pathogenic mechanisms underlying HIV-1 protease inhibitor-associated lipodystrophy are still largely unknown. Methods: Fourteen HIV-infected patients with HIV-1 protease inhibitor-associated lipodystrophy had a biopsy of subcutaneous fat performed in the antero-lateral aspect of the right leg. The samples were submitted for standard pathologic study together with a careful search for adipocyte apoptosis. Apoptosis was assessed by the terminal deoxynucleotidyl transferase dUTP-digoxigenin nick end labelling (TUNEL) method, using the ApopTag kit (Oncor, Gaithersburg, Maryland, USA). The procedure was performed between three and five times for each sample. Appropriate positive and negative controls were used. Controls which were subcutaneous fat biopsies from patients with untreated melanoma were also examined for the presence of apoptosis. Results: Fourteen HIV-infected patients with a mean exposure to HIV-1 protease inhibitors of 12.6 ± 3.7 months (range: 6-21 months), developed the characteristic features of HIV-1 protease inhibitor-associated lipodystrophy. All but one patient had an abnormal waist : hip ratio, and they all exhibited an abnormal serum lipid profile. Pathologically, subcutaneous fat atrophy was a constant feature, along with focal lipogranuloma formation and vascular proliferation. One of the eleven assessable biopsy samples was negative for the presence of apoptosis, six showed focally positive apoptotic cells, and the remaining four biopsies demonstrated moderate positivity. Apoptotic changes were also detected in endothelial cells. Apoptotic changes were more pronounced in patients with higher increases in CD4 and CD8 counts, and in those with a greater decay in plasma viral load. Conclusions: Subcutaneous adipocyte apoptosis occurs in lipoatrophic areas of patients with HIV-1 protease inhibitor-associated lipodystrophy.

Liver granulomas have long been known to pose diagnostic problems for pathologists; however, their prevalence and associated etiologic factors have not been studied in liver transplant patients. We reviewed 3632 liver biopsy specimens from 563 patients at two institutions and identified 42 patients with posttransplant granulomas. A possible or probable etiologic factor was identified in 30 (71%) cases. Most were epithelioid granulomas and microgranulomas located in the parenchyma associated with hepatocyte necrosis (21 cases, 50%). Portal-based granulomas were associated with recurrent primary biliary cirrhosis (5 cases, 12%), acute cellular rejection (2 cases, 4.8%), and a foreign body-type reaction (1 case, 2.4%). One case was associated with tuberculosis (2.4%), 4 cases occurred in a fatty liver (9.5%), and 8 patients had liver granulomas but no other significant abnormality. The granulomas were most frequent in the first 7 months after transplantation when the patients were biopsied more often and underwent episodes of rejection or acute hepatitis. Portal-based granulomas in this period were usually associated with acute cellular rejection. After 7 months, the frequency of granulomas as well as the number of biopsies decreased and portal-based granulomas associated with recurrent primary biliary cirrhosis were most common (5 cases, 12%). Rare, late-appearing parenchymal granulomas were also seen (3 cases) and consisted of 1 lipogranuloma and 2 cases of epithelioid granuloma. The latter were thought, in 1 patient, to be associated with parenchymal hepatocyte necrosis; the others were of unknown etiology.