Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans.

LEARNING OBJECTIVES: After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.

Endoscopic intrauterine surgery in primates: overcoming technical obstacles.

Current protocols for fetal surgery require cesarean section and partial fetal extraction, both of which impart significant risks to the mother and fetus. Endoscopic fetal surgery is less invasive and will likely reduce some of these risks, but the technical difficulties and feasibility in a primate model have yet to be explored fully. Four pregnant baboons (95 days gestation) were anesthetized, their uteruses exposed via an abdominal incision, and blunt-tipped flanged endoscopic ports inserted. Amniotic fluid was removed, and warmed saline was infused to dilate the uterus. To evaluate instrumentation and wound closure, the tip of the snout was externalized and bilateral cleft lip-like defects made. The lips were then endoscopically repaired by suture (Endostitch, U.S. Surgical) or unique nonpenetrating clips (VCS, U.S. Surgical). The saline was then removed, amniotic fluid returned, and the ports carefully removed. After 4 weeks, the fetuses were delivered and evaluated. Eight cleft lip-like defects were successfully repaired in all four cases. Operative time averaged 83 min. No infections, amniotic leaks, or adhesions developed. Survival was 50% with two fetuses delivering within 48 hours postoperatively: one from preterm labor, the other with fetal demise from retroperitoneal hemorrhage after operative blunt abdominal trauma. We demonstrate the feasibility of endoscopic fetal surgery in primates. The use of blunt-tipped flanged ports provides a fluid tight seal and allows appropriate closure of the fetal membranes, but requires laparotomy and uterine exposure. Distension of the uterus with warmed saline affords a larger operating field, enhancing visualization and instrumentation of the fetus. Grasping the fetus through the exposed uterus gives excellent control for repair. However, such control is also needed in a percutaneous approach. Further instrumentation development is needed to accomplish similar control for the percutaneous approach.

Soft tissue injection of hydrocarbons: a case report and review of the literature.

Hydrocarbon injection, while commonly seen in domestic accidents or attempted suicide, is not extensively addressed in the literature. This article comprises a review of the various complications of intravascular and soft tissue injection of petroleum distillates, and provides recommendations for patient management. An illustrative case involving the subcutaneous injection of dripless oil, a mixture of mineral oil, nonionic detergents, and petroleum naphtha, is presented.

Nasolabial fasciocutaneous free flap for cheek defects.

The nasolabial fasciocutaneous free flap provides another option for the reconstruction of cheek defects. The flap can offer excellent skin texture and color match, precise donor and recipient vessel size match, and the potential for a superior donor-site scar.

Long-term results of irradiation for basal cell carcinoma of the skin of the nose.

The long-term outcome of basal cell carcinoma of the nose in patients treated with radiation therapy has not been well documented. To make this evaluation, we assessed the cosmetic and oncologic results in 26 patients after an average interval of 9.3 years following radiation therapy. The majority of the patients were treated with only three doses of radiation from a superficial 50-kVp unit. The cosmetic result was evaluated independently by the patient and two of the authors using a defined grading system. The local control rate was 96 percent, with none of the patients having recurrence noted at the follow-up examination. The patient evaluated the cosmetic result as excellent or good in 81 percent (21 of 26) of cases and physicians in 77 percent (20 of 26) of cases. The cosmetic result appears to remain stable over time; 86 percent of the patients treated more than 13 years ago were rated as having an excellent or good cosmetic result. These data suggest that superficial irradiation is associated with good to excellent cosmetic results in most patients and should be considered an important treatment option for patients with basal cell carcinoma of the skin of the nose.