Antonio Orlando

Erythromycin sclerotherapy in the management of seroma

Post-operative seroma can present the clinician and patient with a chronic and difficult problem. The authors present their experience of managing refractory seroma with the antibiotic erythromycin, administered for its properties as a sclerosant. The technique was found, in a series of patients, to be effective, simple and without serious complications.

Massive plexiform neurofibroma with associated meningo-encephalocoele and occipital bone defect presenting as a cervical mass.

The commonest skull manifestations in neurofibromatosis involve the orbit, with very few reports about occipital defects. We report a rare case of a 54-year-old lady with a massive plexiform neurofibroma extending from the auricular region down her left neck and into her shoulder, with an associated large left occipital and left petrous bone defect and extensive cerebellar meningo-encephalocoele, which presented with a relatively asymptomatic cervical mass and was treated with resection of the neurofibroma and advancement and rotational skin flaps.

Melanoma with an unknown primary--a case series.

Metastatic melanoma of unknown primary site accounts for approximately 5-10% of patients with metastatic melanoma. Various reasons have been suggested for the primary being unknown. These include a hidden location, complete regression of the primary or a primary origin of melanoma in lymph nodes. 24 cases with metastatic melanoma with primary of unknown site are presented. The characteristics and follow-up of the patients are discussed.

Nodal metastatic melanoma in the neck of a 4-year-old girl after diagnosis of Spitz nevus of the cheek.

A 4-year-old girl was referred to the plastic surgery unit with metastatic malignant melanoma diagnosed in a cervical lymph node. She had previously undergone excision of a Spitz nevus of the cheek at age 18 months. The management of this patient is discussed along with a review of the literature relating to Spitz nevi and malignant melanoma in childhood.

Trigeminal trophic syndrome: diagnosis and management difficulties.

Trigeminal trophic syndrome is a rare complication after peripheral or central damage to the trigeminal nerve, characterized by sensorial impairment in the trigeminal nerve territory and self-induced nasal ulceration. Conditions that can affect the trigeminal nerve include brainstem cerebrovascular disease, diabetes, tabes, syringomyelia, and postencephalopathic parkinsonism; it can also occur following the surgical management of trigeminal neuralgia. Trigeminal trophic syndrome may develop months to years after trigeminal nerve insult. Its most common presentation is a crescent-shaped ulceration within the trigeminal sensory territory. The ala nasi is the most frequently affected site. Trigeminal trophic syndrome is notoriously difficult to diagnose and manage. A clear history is of paramount importance, with exclusion of malignant, fungal, granulomatous, vasculitic, or infective causes. We present a case of ulceration of the left ala nasi after brainstem cerebrovascular accident.

Early discharge protocol for regional node dissections for skin cancer: The Frenchay Hospital Lymphadenectomy Algorithm

The Plastic Surgery Unit at Frenchay Hospital, Bristol has developed a treatment algorithm (January 2011) for patients with suspected metastatic lymphadenopathy, to streamline the patient’s care pathway by reducing any delay in treatment and post-operative hospital stay. Nine consultant plastic surgeons used to undertake lymphadenectomies for metastatic skin malignancies; these are now performed by 3 consultant plastic surgeons. The outcome of 50 consecutive patients, treated as per the new algorithm over a 16 month period by the senior author, between January 2011eMay 2012, was reviewed, and compared to that of 50 consecutive patients treated between 2007 and 8.

Butterfly-shape scalp excision: A single stage surgical technique for cutis verticis gyrata

Cutis verticis gyrata (CVG) is well documented in the literature as an idiopathic benign distinctive folding condition of the scalp. Garden and Robinson’s modified classification in 1984, described primary essential, primary nonessential and secondary forms. Surgery has often been advocated, where appropriate, requiring small elliptical or serial excisions combined with tissue expansion or skin excision restricted to the supragaleal plane. We present here a single-stage technique that combines a ‘butterfly’-shaped scalp skin excision design and sub-galeal scalp relaxation incisions addressing all the required areas. A 28-year old man presented with well-established convoluted skin of the frontal, parietal and occipital scalp. He had become increasingly anxious about the unwanted negative attention his appearance attracted. Longer hair had lead to common symptoms of maceration and unpleasant odours from the scalp ‘sulci’, the hygiene of which was more effectively controlled by adoption of short hairstyles, exacerbating his appearance. His medical history and clinical examination were normal, supported by preoperative investigations and scalp skin biopsy. Primary essential cutis verticis gyrata was diagnosed. Surgery was performed under general anaesthesia with the patient positioned prone. A ‘butterfly’-shaped excision was marked to address both parietal and occipital scalp, but affording wider access for sub-galeal scalp scoring of residual scalp (Figure 1). Standard skin marker ink and hypodermic needle was used to ‘tattoo’ the course of the scalp fold ridges and grooves through to the galea aponeurotica (Figure 2). Monopolar cutting diathermy was used to score, hence release, along the tattooed concavities of

Intranodal palisaded myofibroblastoma presenting as lymphadenopathy of the groin.

A 69-year-old lady was referred to the general surgeons for the assessment of a left groin mass. An ultrasound scan was requested, which confirmed a well-defined hypoechoic ovoid mass (3.8 × 2.9 × 2.7 cm) suspicious of soft tissue sarcoma or lymph node metastasis. She was then referred to a plastic surgeon as an outpatient. She presented with a 3-month history of a painless left groin mass increasing in size. There were no other masses palpated and other than lethargy and a recent cough, she had no other symptoms. She had no family history of malignancy, but did have a history of Bowens disease on the right shin excised 3 years previously under the care of the dermatologists. Her previous medical history …

Intraoperative diagnostic cytology of intra-parotid lymph nodes

Intraoperative diagnostic cytology can be utilised instead of frozen section in selected cases. It can be useful when there is a high level of clinical suspicion of malignancy but previous fine needle aspirations (FNAs) of a suspicious palpable mass have been inconclusive. It has advantages over frozen section because it is quicker, requires less equipment and does not involve transection of the specimen. Two case studies are presented below: