Search

Background The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. Objectives To formulate a rational theory for DTN development and their avoidance and treatment. Methods A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought. Consensus was set at 75% agreement. Results Consensus was reached in 16 of 20 questions regarding the pathogenesis of DTNs, forming the basis for a classification and treatment guide. Conclusions The group believes that filler, pathogens, and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen, if the skin barrier is altered. The initially high molecular weight HA filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viremia or vaccination. Systemic pathogenic bacteremia may also interact with the filler peripheral LMWHA, activating Toll-like receptors that induce DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors—filler, inflammation, and infection—separately. Level of Evidence: 4

Background The inverted-V deformity is an unwanted aesthetic consequence of dorsal hump resection. Despite their attachment to the nasal bones, the upper lateral cartilages (ULCs) can separate from the nasal bones, creating a step-off after cartilaginous dorsal hump removal. Objectives The mechanism of how the ULCs can separate from the nasal bones despite their attachment was studied to improve understanding of the inverted-V complication and its prevention. Methods A dorsal hump resection (bony and cartilaginous) was performed on 12 fresh cadavers to observe the effect on the ULCs. As a secondary study, the effect of different preventative maneuvers was investigated. Results Cartilaginous dorsal resection destroys the spreader mechanism of the T-frame and impacts the stabilization of the ULCs, resulting in them becoming free-floating. This causes them to migrate in a posterior, medial, and cranial direction relative to the nasal bones. The dynamic attachment of the ULCs to the nasal bones is key in this mechanism and allows actual separation of the ULCs from the nasal bones to result in the inverted-V deformity. Caudal traction to the ULCs re-tensions these attachments, pulling the ULCs against the nasal bones again. Conclusions This anatomic dissection study has established that the connection between the nasal dorsum and ULCs is not a static fusion but is dynamic. This attachment can be used in primary rhinoplasty to prevent inverted-V deformity by applying caudal traction to the ULCs when reconstructing the dorsum which will tension the ULCs toward the nasal bones.

Background Aspiration prior to hyaluronic acid filler injection is often taught as a safety maneuver to minimize the risk of intravascular injection; however, the validity of this technique in aesthetic practice is being increasingly challenged. One key assumption underpinning the validity of the aspiration test is that the needle tip does not move during the aspiration and subsequent injection of filler. Objectives The aim of this study was to visualize and measure needle tip movement in real time during aspiration and injection of filler. Secondary objectives were to assess the impact of injector experience and double-handed versus single-handed aspiration technique in maintaining stability of the syringe. Methods Under real-time ultrasound visualization, 3 injectors with different levels of experience injected hyaluronic acid filler into pork belly tissue utilizing both double-handed and single-handed aspiration techniques. Needle tip movements were recorded and measured by means of ultrasound and video. Results The aspiration maneuver is in all cases associated with retrograde movement of the needle tip, ranging from 1.1 to 5.3 mm (mean, 2.9 mm), whereas injection leads to anterograde movement ranging from 0.6 to 4.1 mm (mean, 1.9 mm). Double-handed aspiration is associated with less needle tip movement than single-handed aspiration (P = 0.037). Greater experience is also associated less movement of the needle tip (P Conclusions In all cases, the aspiration and injecting maneuver is associated with micromovements of the needle tip, of a magnitude consistently significant relative to the typical size of facial vessels. Although needle tip movement is only a single factor limiting the usefulness of the aspiration test, the results of this study suggest that it is not advisable to rely only on aspiration as a method to prevent intravascular injection.

Background Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration. Objectives The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient. Methods Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined. Results The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection. Conclusions To prevent intravascular injection, understanding “injection anatomy” and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on. Level of Evidence: 4

Standardisation of image acquisition in Aesthetic Plastic Surgery is critical to accurately communicate changes from cosmetic surgical and non-surgical interventions. Depth of Field, Exposure, Perspective and point of view are the four factors that need to be replicated between photographic sessions to accurately represent these changes without the introduction of photographic bias. Despite many excellent articles on standardisation in plastic surgery photography, no paper fully discusses the four areas that lead to consistency in photographs taken at different times. Depth of field, exposure, perspective and point of view cover all the variables required. We have a system which locks many variables in place, leaving final composition matching to the photographer, the only area that needs intelligent input. There are also misunderstandings in the literature about some of these that need explanation, particularly exposure and perspective.

We have read with interest the article by Tseng et al on a retrospective personal survey of positive aspiration.1 However, we are unable to understand what message this article is trying to convey. It is a truly impressive testament to accurate record-keeping and analysis and is instructive in a number of areas. The incidence of positive aspirations from the seemingly safe supraperiosteal plane is sobering. It would tend to suggest that relying purely on depth of injection as a safety measure is inadequate. Interestingly, the article states no adverse vascular events were noted in patients with a positive aspiration. The article, however, makes no mention as to whether any adverse vascular events occurred in patients with negative aspiration treated by the author over the study period. This is important, for others have reported vascular accidents despite negative aspiration.2

Background Hyaluronic acid fillers have a satisfactory safety profile. However, adverse reactions do occur, and rarely intravascular injection may lead to blindness. Currently there is no internationally recognized consensus on the prevention or management of blindness from hyaluronic acid filler. Objectives The authors sought to give guidance on how to minimize the risk and optimize the management of this rare but catastrophic adverse reaction. Methods A multinational group of experts in cosmetic injectables from multiple disciplines convened to review current best practice and develop updated consensus recommendations for prevention and bedside intervention if visual loss occurs after cosmetic injection of hyaluronic acid filler. Results The consensus group provided specific recommendations focusing on the consenting process, prevention, and early management of visual impairment related to intravascular hyaluronic acid filler injection. Conclusions Although visual loss due to filler injections is rare, it is important that both patient and physician be aware of this risk. In this paper the authors describe methods and techniques available to reduce the risk and also document suggested initial management should a clinician find themselves in this situation. Level of Evidence: 5

Despite the recent publication in March 2020 of guidelines for facial injectable treatments, the speed of the COVID-19 pandemic and its safety implications necessitate changes to these guidelines The authors described what would constitute safest practice in the provision of facial injectable treatments and summarised these in table form. Adherence to a high standard of asepsis and infectious disease precautions remain a key patient safety requirement when performing facial aesthetic injections. A revision and update of these guideline summary tables follows. Changes made should enhance both patient and staff safety regarding COVID-19/SARS-CoV-2, a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions and contaminated fomites. Some of the additions are COVID-19 specific and are likely to evolve and change, particularly should serological tests determining acquired immunity become available. Other additions represent further tightening of our infection control precautions.

BACKGROUND The development of chronic nodules and granulomatous inflammation after filler injections has been attributed to bacterial biofilm infection. The authors aimed to investigate the relationship between filler and bacterial biofilm using a combined in vitro and in vivo study. METHODS In vitro assays to investigate the ability of filler materials to support the growth of Staphylococcus epidermidis biofilm and the effect of multiple needle passes through a biofilm-contaminated surface were designed. Analysis of clinical biopsy specimens from patients presenting with chronic granulomas following filler administration using a number of laboratory tests for biofilm was performed. RESULTS All fillers (i.e., hyaluronic acid, polyacrylamide gel, and poly-L-lactic acid) supported the growth of S. epidermidis biofilm in vitro. Multiple needle passes through a biofilm-contaminated surface resulted in significantly increased contamination of filler material by a factor of 10,000 (p < 0.001). Six clinical samples from five patients all demonstrated bacterial biofilm. The mean number of bacteria was found to be 2.2 × 10 bacteria/mg tissue (range, 5.6 × 10 to 3.7 × 10 bacteria/mg tissue). Microbiome analysis detected a predominance of Pseudomonas, Staphylococcus, and Propionibacterium as present in these samples. CONCLUSIONS Filler material can support the growth of bacterial biofilm in vitro. Multiple needle passes can significantly increase the risk of filler contamination. Biofilm appears to be associated with high numbers in clinical samples of patients presenting with chronic granulomatous inflammation. Strategies to reduce the risk of bacterial contamination need to be further studied and translated into clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

AIM: This study describes an Australian cohort of paediatric Buruli ulcer (BU) patients and compares them with adult BU patients. METHODS: Analysis of a prospective cohort of all BU cases managed at Barwon Health, Victoria, from 1 January 1998 to 31 May 2018 was performed. Children were defined as ≤15 years of age. RESULTS: A total of 565 patients were included: 52 (9.2%) children, 289 (51.2%) adults aged 16-64 years and 224 (39.6%) adults aged ≥65 years. Among children, half were female and the median age was 8.0 years (interquartile range 4.8-12.3 years). Six (11.5%) cases were diagnosed from 2001 to 2006, 14 (26.9%) from 2007 to 2012 and 32 (61.5%) from 2013 to 2018. Compared to adults, children had a significantly higher proportion of non-ulcerative lesions (32.7%, P

Intravascular injection leading to skin necrosis or blindness is the most serious complication of facial injection with fillers. It may be underreported and the outcome of cases are unclear. Early recognitions of the symptoms and signs may facilitate prompt treatment if it does occur avoiding the potential sequelae of intravascular injection. To determine the frequency of intravascular injection among experienced injectors, the outcomes of these intravascular events, and the management strategies. An internet-based survey was sent to 127 injectors worldwide who act as trainers for dermal fillers globally. Of the 52 respondents from 16 countries, 71 % had ≥11 years of injection experience, and 62 % reported one or more intravascular injections. The most frequent initial signs were minor livedo (63 % of cases), pallor (41 %), and symptoms of pain (37 %). Mildness/absence of pain was a feature of 47 % of events. Hyaluronidase (5 to >500 U) was used immediately on diagnosis to treat 86 % of cases. The most commonly affected areas were the nasolabial fold and nose (39 % each). Of all the cases, only 7 % suffered moderate scarring requiring surface treatments. Uneventful healing was the usual outcome, with 86 % being resolved within 14 days. Intravascular injection with fillers can occur even at the hands of experienced injectors. It may not be always associated with immediate pain or other classical symptoms and signs. Prompt effective management leads to favorable outcomes, and will prevent catastrophic consequences such as skin necrosis. Intravascular injection leading to blindness may not be salvageable and needs further study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re-emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible.

Mycobacterium ulcerans causes significant morbidity in various endemic locations in Australia and West Africa. The commonest presentation is as a necrotic ulcer often with surrounding subcutaneous necrosis and oedema, which can cause significant morbidity, deformity and functional impairment. Traditional treatment was wide excision and debridement with grafting or flap reconstructions further adding to morbidity and with high recurrence rates. Following publication of clinical studies where antibiotics were shown to be effective, treatment has moved towards combination management with systemic antibiotics and limited surgery involving mainly debridement of the ulcers. Identification of the 'paradoxical' immune-reconstitution syndrome has also impacted upon the extent of excision required. This paper will present the evolution in clinical management of M. ulcerans cases on the Bellarine Peninsula, Victoria, Australia.

OBJECTIVE: To describe the epidemiology, clinical features and diagnosis of Mycobacterium ulcerans infection occurring on the Bellarine Peninsula in Victoria. DESIGN, SETTING AND PATIENTS: Analysis of prospectively collected data on all patients with confirmed M. ulcerans infection reported from the Bellarine Peninsula and managed at Barwon Health between 1 January 1998 and 2 September 2011. MAIN OUTCOME MEASURES: Proportion of cases by age group and sex; duration of symptoms; number, type and site of lesions; proportions diagnosed by polymerase chain reaction (PCR) testing and mycobacterial cultures. RESULTS: We identified 180 sequential cases of M. ulcerans infection: 42 cases in 1998-2004 and 138 in 2005-2011. Median patient age was 61 years (range, 1-94 years), and 49% of patients were male. Duration of symptoms before diagnosis varied from 2 to 270 days (median, 42 days). At presentation, 95% of patients had single lesions. Lower limbs were the most common site of lesions (61%), followed by upper limbs (34%); 40% occurred over a joint. Most lesions presented as ulcers (87%). Compared with the rest of the study population, patients aged > 60 years were more likely to have multiple lesions (odds ratio [OR], 8.1; 95% CI, 1.0-176.2; P = 0.04), and patients aged < 15 years were less likely to have lesions over a joint (OR, 0.2; 95% CI, 0.0-1.0; P = 0.02). Upper limb lesions were more common (OR, 2.2; 95% CI, 1.1-4.3; P = 0.02) and lower limb lesions less common (OR, 0.5; 95% CI, 0.5-0.9; P = 0.01) in male than female patients. Lesion swabs were PCR-positive in 99% of those tested, and positive on mycobacterial culture in 19%. Lesion biopsy samples were PCR-positive in 95% and mycobacterial culture-positive in 47%. CONCLUSIONS: M. ulcerans infections are increasing in the Bellarine Peninsula. They usually present as single ulcerative lesions on limbs, commonly over joints. Age and sex influence clinical presentation, and PCR of lesions has high diagnostic sensitivity.

Background Healing times following treatment with antibiotics, and factors that influence healing, have not been reported in Australian patients with Mycobacterium ulcerans. Methodology/Principal findings Healing times were determined for all M. ulcerans cases treated by a single physician with antibiotics at Barwon Health, Victoria, from 1/1/13-31/12/16. Lesions were categorised by induration size: category A ≤ 400mm2, Category B 401-1600mm2 and Category C ≥1601mm2. A logistic regression analysis was performed to determine risk factors for prolonged wound healing (>150 days from antibiotic commencement). 163 patients were included; 92 (56.4%) were male and median age was 58 years (IQR 39–73 years). Baseline lesion size [available in 145 (89.0%) patients] was categorised as A in 46 (31.7%), B in 67 (46.2%) and C in 32 (22.1%) patients. Fifty (30.7%) patients had surgery. In those treated with antibiotics alone, 83.0% experienced a reduction in induration size after 2 weeks, then 70.9% experienced an increase in induration size from the lowest point, and 71.7% experienced an increase in ulceration size. A linear relationship existed between the time induration resolved and wound healing began. Median time to heal was 91 days (IQR 70–148 days) for category A lesions; significantly shorter than for category B lesions (128 days, IQR 91–181 days, p = 0.05) and category C lesions (169 days, IQR 159–214 days, p, Author summary In our study we have described for the first time in a large cohort of Australian patients the natural history of wound healing of Mycobacterium ulcerans lesions following treatment with antibiotics. We have shown that the lesions usually initially clinically improve with a reduction in induration size, and then deteriorate with increased induration and ulceration, prior to healing after the inflammation associated with lesions resolves. The time to complete healing of lesions is generally long (on average 4.5 months), and is further prolonged in those with increasing initial lesion size or in those who develop paradoxical reactions. In some cases excisional surgery of lesions can reduce healing times by 1–2 months. Knowledge of the natural history of wound healing on antibiotics provides important prognostic information for patients and clinicians when managing Mycobacterium ulcerans disease. This information is also needed as a baseline to assess the impact of new interventions aimed at improving healing times. Furthermore, knowledge of factors that affect wound healing times may lead to interventions that significantly reduce them, and in turn the quality and effectiveness of M. ulcerans treatment.

Objective: To describe the effect of antibiotics on outcomes of treatment for Buruli or Bairnsdale ulcer (BU) in patients on the Bellarine Peninsula in south-eastern Australia. Design: Observational, non-randomised study with data collected prospectively or through medical record review. Patients and setting: All 40 patients with BU managed by staff of Barwon Health’s Geelong Hospital (a public, secondary-level hospital) between 1 January 1998 and 31 December 2004. Main outcome measures: Epidemiology, clinical presentation, diagnosis, treatment and clinical outcomes. Results: There were 59 treatment episodes; 29 involved surgery alone, 26 surgery plus antibiotics, and four antibiotics alone. Of 55 episodes where surgery was performed, minor surgery was required in 22, and major surgery in 33. Failure rates were 28% for surgery alone, and 19% for surgery plus antibiotics. Adjunctive antibiotic therapy was associated with increased treatment success for lesions with positive histological margins (P < 0.01), and lesions requiring major surgery for treatment of a first episode (P < 0.01). The combination of rifampicin and ciprofloxacin resulted in treatment success in eight of eight episodes, and no patients ceased therapy because of side effects with this regimen. Conclusions: Adjunctive antibiotic therapy may increase the effectiveness of BU surgical treatment, and this should be further assessed by larger randomised controlled

We present the first clinical descriptions of immune-mediated paradoxical reactions to effective antibiotic treatment for Mycobacterium ulcerans infection, which result in clinical deterioration after initial improvement. Recognition of this phenomenon could prevent unnecessary changes to antibiotic regimens, and might obviate the need for, or reduce the extent of, further surgery.

Vascular pedicle implantation into the subdermal level of the skin induces an angiogenic response that can be sufficient to artificially create or "prefabricate" an axial-pattern flap suitable for island pedicle or free-flap transfer. This technique allows the creation of large, thin skin flaps that retain the qualities of the donor-site skin. Three cases are presented in which such thin flaps have been created to cover defects, one on the knee and two on the face. While the reconstructions are satisfactory, difficulties were encountered with venous insufficiency in the flaps after the second-stage transfer. We believe that the complexity and staged nature of these procedures limit their application to highly selected patients, but their role probably lies in the transfer of supraclavicular skin for the reconstruction of facial defects.

• Guidelines reflecting contemporary clinical practice in the management of Buruli ulcer (Mycobacterium ulcerans infection) in Australia were published in 2007. • Management has continued to evolve, as new evidence has become available from randomised trials, case series and increasing clinical experience with oral antibiotic therapy. • Therefore, guidelines on the diagnosis, treatment and prevention of Buruli ulcer in Australia have been updated. They include guidance on the new role of antibiotics as first-line therapy; the shortened duration of antibiotic treatment and the use of all-oral antibiotic regimens; the continued importance, timing and role of surgery; the recognition and management of paradoxical reactions during antibiotic treatment; and updates on the prevention of disease.

Background Mycobacterium ulcerans (MU) is responsible for disfiguring skin lesions and is endemic on the Bellarine peninsula of southeastern Australia. Antibiotics have been shown to be highly effective in sterilizing lesions and preventing disease recurrences when used alone or in combination with surgery. Our practice has evolved to using primarily oral medical therapy. Methods From a prospective cohort of MU patients managed at Barwon Health, we describe those treated with primary medical therapy defined as treatment of a M. ulcerans lesion with antimicrobials either alone or in conjunction with limited surgical debridement. Results From 1/10/2010 through 31/12/11, 43 patients were treated with exclusive medical therapy, of which 5 (12%) also underwent limited surgical debridement. The median patient age was 50.2 years, and 86% had WHO category 1 and 91% ulcerative lesions. Rifampicin was combined with ciprofloxacin in 30 (70%) and clarithromycin in 12 (28%) patients. The median duration of antibiotic therapy was 56 days, with 7 (16%) receiving less than 56 days. Medication side effects requiring cessation of one or more antibiotics occurred in 7 (16%) patients. Forty-two (98%) patients healed without recurrence within 12 months, and 1 patient (2%) experienced a relapse 4 months after completion of 8 weeks of antimicrobial therapy. Conclusion Our experience demonstrates the efficacy and safety of primary oral medical management of MU infection with oral rifampicin-based regimens. Further research is required to determine the optimal and minimum durations of antibiotic therapy, and the most effective antibiotic dosages and formulations for young children., Author Summary Mycobacterium ulcerans (MU) is responsible for disfiguring skin infections which are challenging to treat. The recommended treatment for MU has continued to evolve from surgery to remove all involved tissue, to the use of effective combination oral antibiotics with surgery as required. Our study describes the oral medical treatment utilised for consecutive cases of MU infection over a 15 month period at our institution, in Victoria, Australia. Managing patients primarily with oral antibiotics results in high cure rates and excellent cosmetic outcomes. The success with medical treatment reported in this study will aid those treating cases of MU infection, and will add to the growing body of knowledge about the relative roles of antibiotics and surgery for treating this infection.

Mycobacterium ulcerans causes significant morbidity in various endemic locations in Australia and West Africa. The commonest presentation is as a necrotic ulcer often with surrounding subcutaneous necrosis and oedema, which can cause significant morbidity, deformity and functional impairment. Traditional treatment was wide excision and debridement with grafting or flap reconstructions further adding to morbidity and with high recurrence rates. Following publication of clinical studies where antibiotics were shown to be effective, treatment has moved towards combination management with systemic antibiotics and limited surgery involving mainly debridement of the ulcers. Identification of the 'paradoxical' immune-reconstitution syndrome has also impacted upon the extent of excision required. This paper will present the evolution in clinical management of M. ulcerans cases on the Bellarine Peninsula, Victoria, Australia.

Introduction Mycobacterium ulcerans (M. ulcerans) is a necrotizing skin infection endemic to the Bellarine Peninsula, Australia. Current treatment recommendations include 8 weeks of combination antibiotics, with adjuvant surgery if necessary. However, antibiotic toxicity often results in early treatment cessation and local experience suggests that shorter antibiotic courses may be effective with concurrent surgery. We report the outcomes of patients in the Barwon Health M. ulcerans cohort who received shorter courses of antibiotic therapy than 8 weeks. Methodology / Principal findings A retrospective analysis was performed of all M. ulcerans infections treated at Barwon Health from March 1, 1998 to July 31, 2013. Sixty-two patients, with a median age of 65 years, received < 56 days of antibiotics and 51 (82%) of these patients underwent concurrent surgical excision. Most received a two-drug regimen of rifampicin combined with either ciprofloxacin or clarithromycin for a median 29 days (IQR 21–41days). Cessation rates were 55% for adverse events and 36% based on clinician decision. The overall success rate was 95% (98% with concurrent surgery; 82% with antibiotics alone) with a 50% success rate for those who received < 14 days of antibiotics increasing to 94% if they received 14–27 days and 100% for 28–55 days (p, Author Summary Buruli ulcer is a necrotizing skin and subcutaneous tissue infection caused by Mycobacterium ulcerans and is the third most common mycobacterial infection, behind tuberculosis and leprosy, world-wide. In recent years, the World Health Organisation has modified its guidelines for M. ulcerans treatment, moving from predominantly surgical to predominantly medical based management. It now recommends the combination of oral rifampicin and intramuscular streptomycin for a period of eight weeks as first-line therapy, with surgery as adjunctive therapy if necessary. The Barwon Health experience from south-eastern Australia has demonstrated that the entirely oral combination of rifampicin with either ciprofloxacin or clarithromycin for eight weeks can be an effective treatment option. However, these antibiotics are often toxic leading to early cessation, especially in the elderly. In addition, clinicians have been using a shorter duration of therapy for smaller lesions that have also been surgically managed. This study reviews our experience treating M. ulcerans with antibiotic durations of less than 8 weeks and demonstrates that successful outcomes can be achieved in selected patients, with success rates influenced by the duration of treatment and the use of surgical excision. This finding needs confirmation in further studies, but could have significant benefits in terms of reducing toxicity and improving adherence associated with Buruli ulcer antibiotic treatment.

A retrospective study was performed of 30 women who had undergone breast reduction and subsequently wished to breastfeed. Breastfeeding capabilities were assessed by a trained lactation consultant. Findings indicate that in women who have a physiological type of operation then breastfeeding is usually possible (18 patients out of 19), although complementary feeds may be required. We strongly suggest that all functioning breast tissue that remains after reduction mammaplasty be left attached to the nipple in a physiological manner to allow subsequent breastfeeding.

Background Paradoxical reactions from antibiotic treatment of Mycobacterium ulcerans have recently been recognized. Data is lacking regarding their incidence, clinical and diagnostic features, treatment, outcomes and risk factors in an Australian population. Methods Data was collected prospectively on all confirmed cases of M. ulcerans infection managed at Barwon Health Services, Australia, from 1/1/1998-31/12/2011. Paradoxical reactions were defined on clinical and histological criteria and cases were determined by retrospectively reviewing the clinical history and histology of excised lesions. A Poisson regression model was used to examine associations with paradoxical reactions. Results Thirty-two of 156 (21%) patients developed paradoxical reactions a median 39 days (IQR 20-73 days) from antibiotic initiation. Forty-two paradoxical episodes occurred with 26 (81%) patients experiencing one and 6 (19%) multiple episodes. Thirty-two (76%) episodes occurred during antibiotic treatment and 10 (24%) episodes occurred a median 37 days after antibiotic treatment. The reaction site involved the original lesion (wound) in 23 (55%), was separate to but within 3 cm of the original lesion (local) in 11 (26%) and was more than 3 cm from the original lesion (distant) in 8 (19%) episodes. Mycobacterial cultures were negative in 33/33 (100%) paradoxical episodes. Post-February 2009 treatment involved more cases with no antibiotic modifications (12/15 compared with 11/27, OR 5.82, 95% CI 1.12-34.07, p = 0.02) and no further surgery (9/15 compared with 2/27, OR 18.75, 95% CI 2.62-172.73, p