Neurofibromatosis Type 1: Review of Cutaneous and Subcutaneous Tumor Treatment on Quality of Life.

BACKGROUND: Neurofibromatosis Type 1 (NF1) is the most common type of neurogenetic disorder with a worldwide incidence of between 1 in 2,600 and 1 in 3,000. NF1 has a wide range of manifestations; as a result, NF1 has no "public persona." Beginning at puberty and continuing thereafter patients may grow cutaneous and subcutaneous tumors (neurofibromas) in large numbers, which cause severe problems with appearance, which are similar in severity to those of psoriasis. Appearance concerns due to tumors affect NF1 patients' Quality of Life (QoL). NF1 patients are at increased risk for depression and treatment for depression and significantly enhance QoL. Improving appearance and QoL by decreasing the number of tumors is the NF1 patient's greatest concern. Improving QoL is an end in itself. METHODS: There are no currently available medical or pharmacological treatments for cutaneous and subcutaneous tumors of NF1. Surgery is the only treatment option for cutaneous and subcutaneous tumors. High Quantity (HQ) surgical removal by several methods has been used. RESULTS: HQ electrosurgical (ES) allows removal of large numbers of tumors, hundreds per surgical session, appears to be highly effective, and most patients are happy with their results. Other surgical techniques, such as scalpellic surgery, are not effective. Inadequate insurance payments, few plastic surgeons performing HQ tumor removal, lack of support from nonsurgeon physicians, few if any NF clinics providing HQ tumor removal, pediatric orientation, focus on basic research, and a dismissive attitude toward NF1 patients are all components in the unavailability of HQ NF tumor removal. Such surgery is not cosmetic but restoration of normal appearance from disfigurement due to a congenital, neoplastic disease. CONCLUSIONS: National legislation is required to mandate insurance companies to provide coverage for HQ tumor removal. Payments by health insurance companies to plastic surgeons must be reasonable and comparable with other procedures. Effort by neurologists and other nonsurgeons is needed to gain support of plastic surgeons. Strong pressure is needed by support groups of NF for providing NF1 HQ surgery at institutions with NF clinics and for proper payments for surgeons and others.

Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years.

BACKGROUND: Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates. METHODS: A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training. RESULTS: Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9). CONCLUSIONS: The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.

The incidence of methicillin-resistant Staphylococcus aureus in pressure ulcers.

Colonization of chronic wounds with methicillin-resistant Staphylococcus aureus continues to be an important healthcare concern. Aside from the morbidity associated with infections, colonization alone can contribute to outbreaks at long-term-care facilities and within hospitals. Despite the prevalence of pressure ulcers, the incidence of S aureus in these chronic wounds is unknown.

Reconstruction of the zygomatic arch using a mandibular adaption plate.

Zygomatic complex fractures are one of the most common facial fractures treated by maxillofacial surgeons. Because of the importance of the zygomatic complex in midfacial skeletal orientation, comminuted zygomatic arch fractures can lead to significant morbidity and deformity. Common repair modalities include closed reduction via a Gilles approach, open reduction and internal fixation with screws and/or plating systems, primary bone grafting, and/or biosynthetics. In patients with significant comminution and arch defects, who are poor candidates for bone grafting, reconstruction can be difficult. In this clinical report, we present 2 patients with comminuted zygomatic arch fractures and significant bony defects, who were reconstructed with mandibular adaption plates alone without primary bone grafting. Over a mean follow-up period of 12.5 months, both patients healed well without any complications and had acceptable cosmetic outcomes.

The use of argon beam coagulation in pressure sore reconstruction.

PURPOSE: Pressure sores are a significant source of physical and financial burden for debilitated patients. When conservative measures fail, surgical reconstruction with myocutaneous flaps may be the last hope for cure and/or improved quality of life in these patients. Adequate haemostasis is an integral component of these reconstructive procedures, as bleeding and haematoma formation can lead to increased morbidity. This study was designed to investigate the use of argon beam coagulation in patients undergoing bony debridement and subsequent pressure sore reconstruction with myocutaneous flaps. METHODS: The clinical records of 34 patients undergoing pressure sore reconstruction with the use of argon beam coagulation from 2004 to 2006 at an academic institution were reviewed and outcomes were assessed. RESULTS: Reconstruction was performed by a single surgeon on 34 patients (31 men, three women; mean age 41+/-15 years), with a total of 41 pressure sores. Thirteen (32.5%) patients had evidence of osteomyelitis preoperatively and five (12.5%) had previous coccygectomies secondary to infection. Twenty-six (65%) of the pressure sores were treated with hamstring V-Y musculocutaneous flaps, 10 (25%) with gluteal flaps, and four (10%) with tensor fascia lata flaps. Overall, suture line dehiscence occurred in six (15%) cases, flap failure and pressure sore recurrence occurred in six (15%) cases, an abscess developed in one (2.5%) case, and a sinus tract with a superficial wound developed in one (2.5%) case. There were no complications related to haemostasis, including excessive bleeding or haematoma formation. CONCLUSIONS: Argon beam coagulation is an efficacious tool for achieving adequate haemostasis during pressure sore reconstruction, particularly when significant bony debridement is involved. The use of argon beam coagulation does not result in an increased complication or recurrence rate when compared with conventional electrocautery methods.

Evaluation of (111) indium-labeled autologous leukocyte scintigraphy for the diagnosis of chronic osteomyelitis in patients with grade IV pressure ulcers, as compared with a standard diagnostic protocol.

Diagnosing osteomyelitis in patients with pressure ulcers is complicated by overlying soft-tissue inflammation and reactive bone formation. We set out to evaluate the efficacy of indium scanning in the diagnosis of chronic osteomyelitis in spinal-cord-injury patients with grade IV pressure ulcers. The goal was to estimate the sensitivity and specificity of indium scanning as compared with diagnostic modalities previously evaluated by the principal investigator. Our method was a retrospective chart review of cases at a university hospital. Eleven patients with pressure sores and suspected chronic osteomyelitis underwent indium scanning. The results were compared with ostectomy specimens taken at the time of reconstructive surgery and/or bone biopsy. The sensitivity and specificity were 100% and 50%, respectively. Indium scanning appears to be more sensitive than specific. These data suggest that the value of indium scanning may primarily be to rule out osteomyelitis and not as a primary diagnostic modality.

Urologic and plastic surgical collaboration for continent diversion when urine leakage is complicated by pressure ulcers or obesity.

BACKGROUND: Patients with neurogenic bladder dysfunction and urine leakage combined with pressure ulceration, fistulae, and/or obesity present a major surgical challenge. Given the urgent need to control urine leakage, suprapubic cystostomy or incontinent urinary diversion such as ileal conduit often are chosen for definitive intervention, despite the fact that continent urinary diversion generally is the preferred method of management for the motivated patient. DESIGN: Case series. METHOD: This article presents 4 patients in whom urine leakage was complicated by pressure ulcers, urethral erosion, and/or morbid obesity. Due to the complicated nature of their problems, these patients were managed in a collaborative fashion by the departments of urology, plastic surgery, and physiatry. Each of these patients underwent a combined surgical intervention that addressed issues of skin ulceration or morbid obesity and allowed for continent urinary diversion. RESULTS: After intervention, all 4 patients were independent in bladder management and were completely continent. CONCLUSION: This series demonstrates how collaboration between the urologist and plastic surgeon in evaluation and treatment planning allows for the formulation of surgical options that include continent urinary diversion.

The value of Jamshidi core needle bone biopsy in predicting postoperative osteomyelitis in grade IV pressure ulcer patients.

We present a retrospective review of 108 patients with spinal cord injury who underwent reconstruction of grade IV pressure ulcers between 1989 and 1994. Complications of reconstruction secondary to undetected osteomyelitis, namely, deep abscess and sinus tract formation, and their effect on hospital course after the flap reconstruction were quantitatively evaluated. Specifically, this study assesses whether the use of Jamshidi core needle bone biopsy allows for the accurate diagnosis, and therefore treatment, of osteomyelitis before pressure ulcer closure. Early diagnosis and treatment of osteomyelitis would presumably reduce the complication rate of reconstruction. The 108 patients in the study all underwent intraoperative Jamshidi core needle bone biopsy, and postoperative complications were evaluated by reviewers blinded to results of the biopsies. Of the 25 (23 percent) postoperative complications noted, 14 (13 percent) were attributed to underlying osteomyelitis. Patients with pressure ulcer complicated by osteomyelitis were hospitalized significantly longer than those with no osteomyelitis. On average, the former group stayed for 57 days and the latter 21 days (p < 0.001). All 14 patients who developed complications because of deep abscess and sinus tract formation had intraoperative Jamshidi core needle bone biopsy abnormality consistent with osteomyelitis (positive Jamshidi core needle bone biopsy results). The Jamshidi core needle bone biopsy compares favorably with other published modalities used to diagnose osteomyelitis, including white blood cell count, erythrocyte sedimentation rate, radiologic study, and bone biopsy culture. We propose an algorithm for the management of spinal cord injury patients with grade IV pressure ulcers. This algorithm incorporates the use of preoperative Jamshidi core needle bone biopsy to allow for the diagnosis and treatment of osteomyelitis before the flap reconstruction and to prevent complications of undiagnosed osteomyelitis after reconstruction.