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tissue needed, in order to minimize exposure of the collected tissue to the surrounding environment. Exact guidelines for successful fat transplantation surgery have not yet been established. References

1. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg 2007;120:89S-97S.

2. Valdatta L, Thione A, Buoro M, et al. A case of life-threatening sepsis after breast augmentation by fat injection. Aesthetic Plast Surg 2001;25:347-9.

3. Gutowski KA; ASPS Fat Graft Task Force. Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg 2009;124:272-80.

4. Ryan KJ, Ray CG, Sherris J. Sherris medical micro- biology: an introduction to infectious diseases. 4th ed. New York: McGraw-Hill; 2004.

5. Brook I. The role of encapsulated anaerobic bacteria in synergistic infections. FEMS Microbiol Rev 1994; 13:65-74.

Recurrence of Nevus Lipomatosus Cutaneous Superficialis after CO2 Laser TreatmentYoung Joon Kim, Jung Hun Choi, Hoon Kim, Sang Hyun Nam, Young Woong ChoiDepartment of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea

Correspondence: Sang Hyun Nam Department of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 139-707, Korea Tel: +82-2-950-1048, Fax: +82-2-932-6373E-mail: nsh1103@paik.ac.kr

No potential conflict of interest relevant to this article was reported.

Received: 10 Apr 2012 • Revised: 1 Jun 2012 • Accepted: 2 Jun 2012pISSN: 2234-6163 • eISSN: 2234-6171http://dx.doi.org/10.5999/aps.2012.39.6.671 • Arch Plast Surg 2012;39:671-673

Copyright 2012 The Korean Society of Plastic and Reconstructive SurgeonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nevus lipomatosus cutaneous superficialis (NLCS) is a relatively rare benign malformation characterized

by ectopic deposition of mature adipose tissue in the collagen bundles of the dermis [1-4]. NLCS is clas- sified into two subtypes: the multiple (classical) type and solitary type [1-3]. The multiple type usually appears within the first two decades of life, most com- monly in the pelvic girdle region and consists of flesh-colored or yellow papules or nodules [3,4]. Also, its histopathological features are relatively uniform [3]. In contrast, the solitary type consists of a single nodular lesion without a favored location and it usually occurs in adults [3]. Surgical excision is a simple and adequate treatment for all lesions [2]. Recently, some authors have reported that CO2 laser is useful method of treat- ment for NLCS, especially in the multiple type [4]. We report here a case of multiple type NLCS on the right lower back, which recurred after CO2 laser treatment and was treated by staged surgical excisions. To the best of our knowledge, there have not been any cases of recurred NLCS after laser treatment in the literature. A 13-year-old girl presented with asymptomatic, yellow-orange papules on the right lower back measuring 14 × 5 cm and composed of three clusters (Fig. 1). According to her parents, the skin masses had appeared at age 5 and gradually increased in number and size as she grew. However, there was no evidence of any systemic disease and no symp- toms due to her back mass. Her family history was unremarkable, with a lack of similar skin lesions. Three years earlier, the patient had been treated with CO2 laser at another clinic to avoid the inconvenience of removing her clothes. At that time, they had thought that the mass was treated well. However, a few months

Fig. 1. Clinical photograph of the case. A 14×4 cm nevus lipomatosus cutaneous superficialis lesion on the right flank. Initially, only the central cluster had been presented, but after CO2 laser treatment, 2 more clusters were presented.

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later, remarkably, the skin masses had recurred and increased in numbers and size very rapidly. On physical examination, there were multiple yellow-colored, non-tender, soft nodules coalescing into a plaque on her right lower back. Complete surgical excision was performed divided in three stages and covered with local advancement flaps (Fig. 2). Histopathologically, lobules of the mature adipo- cytes were located between the collagen fibers in the entire dermis. Fat lobules extending to the reticular dermis were located around the capillaries. All of these findings coincide with NLCS (Fig. 3). NLCS is a rare idiopathic benign malformation characterized by ectopic adipose tissue in the dermis [1-3]. Generally, there are no clinical symptoms during its course, although sometimes NLCS can appear with some symptoms [2]. Now NLCS is classified into two subtypes [1-3]. The multiple type usually appears within the first two decades of life, but occa- sionally it can have a later onset [3]. There is no sex or genetic predilection [3]. Usually the multiple type consists of grouped, flesh-colored or yellow papules or nodules on the pelvic girdle region in a segmental pattern that coalesce to form plaques [1,3,5]. The plaque surfaces are smooth, but sometimes they have a verrucous or cerebriform appearance [4,5]. In our case, the skin lesion appeared from age 5 on the right lower back, and there were no clinical symptoms from the NLCS. It presented typical characteristics of mul- tiple type NLCS. The pathogenesis is still unknown and several theories have been proposed [4]. One

theory suggests that multiple type NCLS arises from adipose metaplasia in the course of degenerative changes in the dermal connective tissue [4]. Another theory is that the adipocytes represented a true nevus from the developmental displacement of adipose tissue [4]. A third proposal is that the mature adipo- cytes grow from mononuclear cells that were diffe- rentiating lipoblasts in a perivascular area [1]. The hitopathology of NLCS usually shows clusters of ectopic mature adipose tissues among the collagen bundles in the dermis, and there is no connection to the subcutaneous fat tissue [1,2]. These ectopic adi- pocytes contain large intracytoplasmic lipid vacuoles, often associated with vascular structures [1,4]. Many authors have reported that treatment is not necessary in most cases, other than for cosmesis [2]. However, clinicians should be aware that sometimes the masses can become a larger tumor if untreated [5]. Simple surgical excision is sufficient for treatment without recurrence in almost cases [2]. However, if surgical excision is not adequate, recurrence is pos- sible. Recently, some authors have reported that CO2 laser treatment is effective for treating large lesions of multiple type NLCS without recurrence [4]. They argue that CO2 laser treatment is somewhat better than surgical excision. Because multiple type NLCS usually involves a large area, sometimes it requires a skin graft. These skin grafts could cause unsatisfying cosmetic results, but the study reported that patients treated with CO2 laser were pleased with the results [4]. The authors treated recurred multiple type NLCS

Fig. 2. Photograph 6 months postoperatively. The lesion was completely

excised and there were only wide scars remaining.

Fig. 3. Histopathologic findings of the case. Lobules of mature fat are diffusely

scattered between collagen fibers in the dermis. Fat lobules extending to reticular dermis are located around the capillaries (H&E, ×200).

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after CO2 laser treatment with staged excisions and covered with local advancement flaps, but the patient was satisfied with the cosmetic results and there was no recurrence. Consequently, physicians should take note that insufficient treatment, including CO2 laser or any surgical excision, can cause recurrence, as in this case. We suggest that staged excision can be another treatment modality for large multiple type NLCS. References

1. Jones EW, Marks R, Pongsehirun D. Naevus superficialis lipomatosus. A clinicopathological report of twenty cases. Br J Dermatol 1975;93:121-33.

2. Hattori R, Kubo T, Yano K, et al. Nevus lipomatosus cutaneous superficialis of the clitoris. Dermatol Surg 2003;29:1071-2.

3. Kim KJ, Park BI, Kim YB, et al. Clinical experience of nevus lipomatosus cutaneous superficialis. J Korean Soc Plast reconstr Surg 1994;21:360-4.

4. Jung SJ, Kim HJ, Seo YJ, et al. A case of nevus lipomatosus cutaneous superficialis treated by CO2 laser. Korean J Dermatol 2007;45:1093-5.

5. Knuttel R, Silver EA. A cerebriform mass on the right buttock. Dermatol Surg 2003;29:780-1.

Ecthyma gangrenosum (EG) is a rare but charac- teristic cutaneous and potentially fatal disorder caused by a pseudomonal infection. The characteri- stic cutaneous lesion progresses sequentially, and starting as a maculopapular eruption, advancing to a hemorrhagic bulla, and then evolving into a gangre- nous ulceration with black eschar surrounded by an erythema [1]. EG usually occurs in immunocom- promised patients, but occasionally it affects previ- ously healthy individuals. We present a case of a 10- month-old previously healthy infant with transient severe neutropenia caused by influenza B infection without bacteremia. A previously healthy 10-month-old boy was ad- mitted with a 5-day history of fever, general weakness, and a red spot on the right buttock. The red spot had started as a small papule, after a perineal diaper rash disappeared. Initially, it was thought to be part of the diaper rash, but rapidly progressed to a bulla and finally to a necrotic black eschar with surrounding erythema within only 24 hours, but without suppu- ration (Fig. 1). An initial blood test revealed leukopenia (4,000/μL; normal range, 6,000 to 17,500/μL) with severe neutropenia (absolute neutrophil count, 320/μL; normal range, 3,150 to 6,200/μL), lymphocytosis, and monocytosis. His inflammatory markers were elevated: C-reactive protein 13.9 mg/dL (normal range, 0.08 to 1.12 mg/dL) and erythrocyte sedimen- tation rate 35 mm/hr (normal range, 0 to 9 mm/hr). All other results were in the normal range. However, a nasal smear test revealed positivity for influenza B. At the time of admission, the child was initially given intravenous third-generation cephalosporin for broad spectrum coverage, but the cutaneous lesion continued to progress. A wound culture grew Pseudo-

Ecthyma Gangrenosum in a Previously Healthy InfantSu Han Koo1, Joon Ho Lee1, Heakyeong Shin1, Jong Im Lee2

Departments of 1Plastic and Reconstructive Surgery, and 2Pathology, Dongguk University College of Medicine, Gyeongju, Korea

Correspondence: Heakyeong ShinDepartment of Plastic and Reconstructive Surgery, Dongguk University College of Medicine, 87 Dongdae-ro, Gyeongju 780-350, KoreaTel: +82-54-770-8242, Fax: +82-54-770-8501 E-mail: shinheakyeong@hanmail.net

This article was presented as a poster at the Second Research and Reconstructive Forum of the Korean Society of Plastic and Reconstructive Surgeons on June 1-2, 2012 in Gwangju, Korea.

No potential conflict of interest relevant to this article was reported.

Received: 31 Aug 2012 • Revised: 26 Sep 2012 • Accepted: 26 Sep 2012pISSN: 2234-6163 • eISSN: 2234-6171http://dx.doi.org/10.5999/aps.2012.39.6.673 • Arch Plast Surg 2012;39:673-675

Copyright 2012 The Korean Society of Plastic and Reconstructive SurgeonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Images

Fig. 1. Cutaneous lesion. Typical appearance of ecthyma gangrenosum on the right buttock.