Necrotizing Fasciitis (NF) is a rapidly progressive and potentially lethal infection. This systematic review focused on the treatment and prognosis of the NF of the hand. The literature search was performed in PubMed database, and cohort studies and case reports were deemed eligible. Proportions were pooled to estimate overall mortality and amputation rates, and a logistic regression analysis was performed to evaluate predictors of amputation and mortality. The search algorithm resulted in 51 eligible articles including 48 case reports (54 patients) and 3 larger retrospective cohort studies (107 patients). Most patients had a monomicrobial infection, a surgical debridement on the day of admission, and hospital stay of more than 10 days. The estimated overall amputation rate was 28%, whereas overall mortality was equal to 8%. In the pooled set of case reports, mortality was significantly associated with age older than 54 years and marginally with diabetes mellitus. Necrosis expanding more proximally to the forearm correlated with both amputation and mortality. It is reiterated that early diagnosis of NF is of paramount importance and that early and decisive surgical intervention should have low threshold, especially when potential risk factors are identified.
Tuberous breast deformity refers to a deformity of the breast that is characterized by varying degree of herniation of the breast parenchyma, widened nipple areolar complex, constriction of the breast base and may involve some degree of hypoplasia. Tuberous breast deformity is most often seen in young women who commonly presents due to dissatisfaction with breast symmetry, as this can be a source of significant psychosocial distress. Principles of reconstruction are focused on recreating an aesthetically pleasing breast shape and achieving symmetrization. Traditionally, reconstruction commonly involved utilization of breast implants or local flap to achieve these goals. The introduction of fat transfer has led to a paradigm shift in aesthetic breast surgery. Fat grafting is safe and can reliably achieve satisfactory aesthetic results in selected cases and reduces the need for implants or local flaps. Concepts that reduce scar burden allows for even more satisfactory aesthetic outcomes.
The introduction of breast conservation surgery together with advances in oncoplastic techniques has revolutionized the management of retroareolar breast tumours. Traditionally, cancers in this location were often managed with central excision and primary closure or mastectomy. More recently, oncoplastic breast-conserving techniques such as the Grisotti mammoplasty have been increasingly encouraged as an alternative option as it allows oncological safe margin resections while restoring cosmesis. The use of a Grisotti flap enables safe resection of a retroareolar tumour with concurrent reconstruction of the defect using a local rotational advancement dermoglandular flap allowing a satisfactory cosmetic result in term of contour and projection. This technique is often limited to those patients with sufficient native nipple-inferior mammary fold (IMF) distance to accommodate for some inevitable post-operative reduction in this distance. We describe a modification of the original description, such that satisfactory cosmetic outcome can be achieved, even in patients with a short nipple areolar complex to inframammary fold distance.
Gestational gigantomastia is a psychologically and physically debilitating disease of unknown aetiology. Underlying diseases that present as gigantomastia should be excluded by a thorough workup. Most cases respond to the preferred approach: conservative management, as foetal viability and well-being is of significant importance. However, in those cases where the maternal mortality is at risk, the surgical approach is preferred. Life-threatening haemorrhage may occur and early recognition and treatment is paramount to outcome. A case of gestational gigantomastia complicated by life-threatening haemorrhage is presented and discussed.
monary fibrosis (2). The reported incidence of primary spontaneous pneumothorax is 18 to 28 per 100 000 per year in men and 1.2 to six per 100 000 per year in women (1). Mortality is greater in men than in women.A tension pneumothorax is usually associated with trauma or mechanical ventilation and the incidence of spontaneous development is rare. A spontaneous tension pneumothorax may complicate one to three per cent of unrecognized pneumothoraces (3). This feared complication typically presents with obvious respiratory distress and signs of cardiovascular instability requiring emergency needle decompression and tube thoracostomy.Presented is an interesting case of a young female who presented to the Emergency Room with right-sided chest pain
Neurofibromatosis type 1 (NF-1)—also commonly known as Von Recklinghausen’s disease—is an autosomal dominant disease that represents a constellation of clinical features. There are well-established links between NF-1 and many tumors; however, the link between NF-1 and breast cancer has more recently been elucidated. While the management of breast cancer is generally well established, there are unique challenges noted in patients with NF-1. There may be delayed presentations due to difficulty in differentiating underlying neurofibroma from a sinister breast mass. Additionally, multiple skin lesions seen in NF-1 create challenges in the interpretation of mammography. Furthermore, a surgical conundrum is created, as these patients appear to have a higher risk of angiosarcoma following radiotherapy. A mastectomy may be the best option as it obviates the need for radiation therapy and ongoing surveillance. A case exemplifying these dilemmas and a review of the literature are presented.
Closed flexor digitorum profundus (FDP) tendon avulsions are a recognized injury in hand surgery. However, closed tendon avulsion of both flexor tendons in the same digit is rare, with the few cases reported in the literature and presented here. Management includes primary repair ideally within the first 2 weeks to achieve optimal outcome. While beyond 4 weeks a two-stage repair is the dictum, we present a case where both tendons were avulsed but primary repair of the FDP was possible more than 4 weeks after the injury, with a good outcome. This case highlights that primary tendon repair at 32 days, the longest noted in the literature in this group of patients, can result in a good outcome even if the injury is more than 4 weeks old. However, good intraoperative decision-making is key and the skillset must be present for conversion to a two-stage repair if necessary.
Congenital Ichthyosis represents a very rare group of congenital skin disorders characterized by some degree of scaling and thickening of the stratum corneum with skin inflammation. Severe forms such as Harlequin and Lamellar forms may present with limb and organ compromise, respectively. Patients with Lamellar subtype presents with severe ectropion which may lead to corneal ulceration, rupture and blindness. Treatment includes a multidisciplinary approach allowing for early intervention and treatment, which optimize the outcomes. The timing for intervention is not clearly defined in the literature. This is most likely due to a paucity in data due to the relative infrequency in these conditions. However, using principles similar to early treatment of ectropion in burnt patients may be employed. A case of Lamellar Ichthyosis that presented to our outpatient clinic which was successfully managed with early ectropion release and full thickness skin graft is discussed.
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