Ricky P. Clay

Klippel-Trénaunay syndrome : Spectrum and management

OBJECTIVE To describe a series of 252 patients with Klippel-Trénaunay syndrome (KTS), a rare congenital malformation characterized by the triad of capillary malformations, atypical varicosities or venous malformations, and bony or soft tissue hypertrophy usually affecting one extremity. MATERIAL AND METHODS We reviewed the clinical characteristics and findings in 136 female and 116 male patients with KTS who underwent assessment at Mayo Clinic Rochester between January 1956 and January 1995. In addition, management options are discussed. RESULTS Capillary malformations (port-wine stains) were found in 246 patients (98%), varicosities or venous malformations in 182 (72%), and limb hypertrophy in 170 (67%). All three features of KTS were present in 159 patients (63%), and 93 (37%) had two of the three features. Atypical veins, including lateral veins and persistent sciatic vein, occurred in 182 patients (72%). Operations performed in 145 patients with KTS included epiphysiodesis, stripping of varicose veins or venous malformations, excision of vascular malformations, amputations, and debulking procedures. CONCLUSION Most patients with KTS should be managed conservatively. The clearest indication for operation is a leg length discrepancy projected to exceed 2.0 cm at skeletal maturity, which can be treated with epiphysiodesis in the growing child. If a functioning deep vein system is present, removal of symptomatic varicosities or localized superficial venous malformations in selected patients can yield good results.

Fistula formation and repair after palatal closure : An institutional perspective

&NA; We retrospectively reviewed 119 consecutive patients who underwent cleft palate repair at the Mayo Clinic to determine the incidence of postoperative fistula formation, to assess possible contributing factors, and to review the methods of surgical management. Fistulas of the secondary palate were included, but nasal‐alveolar fistulas and intentionally unrepaired anterior palatal fistulas were excluded. Six patients whose repairs were performed after 2.5 years of age were excluded to ensure a more uniform patient population. Cleft palate fistulas occurred in 13 of the 113 patients (11.5 percent). The median age at repair was 8.2 months, and the median follow‐up period was 5.2 years. Several variables were analyzed by means of the log‐rank test to determine their significance in postoperative fistula formation. Sex, extent of clefting (as estimated by the Veau classification), and type of palatal closure did not significantly affect the rate of fistula formation. However, patients who had palatal closure at an age younger than 12 months had a lower incidence of fistula formation (7.8 percent) than children whose closures were performed between the ages of 12 and 25 months (19.4 percent) (p = 0.058). The strongest predictor of the occurrence of a cleft palate fistula was the surgeon performing the procedure (p = 0.008). Fistula repair was deemed necessary in 11 of 13 patients, and 91 percent of these fistulas were healed with a single operation. Most of these fistulas were closed by using local flaps and two‐layered closures. Cleft palate repair carries a significant but acceptable risk of fistula formation, which can be managed with local flaps. Fistula occurrence is related most to the experience level of the operating surgeon.

Evaluation and Management of Pain in Patients with Klippel-Trenaunay Syndrome: A Review

Klippel-Trenaunay syndrome (KTS) is a rare disorder that consists of a triad of capillary vascular malformation, venous malformations and/or varicose veins, and soft tissue and/or bony hypertrophy. Pain is a real and debilitating problem in these patients. We have observed 9 common causes of pain in KTS: (1) chronic venous insufficiency, (2) cellulitis, (3) superficial thrombophlebitis, (4) deep vein thrombosis, (5) calcification of vascular malformations, (6) growing pains, (7) intraosseous vascular malformation, (8) arthritis, and (9) neuropathic pain. The management of pain in patients with KTS depends on its cause. These patients are best evaluated initially in a center with an experienced multidisciplinary team that includes a primary health care provider, surgeons, and ancillary staff. The ongoing care of a patient with KTS often depends on a local provider who is more readily accessible to the patient but may not have the expertise of a large center to manage the complications of KTS. The purpose of this communication is to review the common causes of pain in these patients to provide local health care providers and patients and their families with appropriate management strategies.

Pilot Study of Association of Bacteria on Breast Implants with Capsular Contracture

ABSTRACT Capsular contracture is the most common and frustrating complication in women who have undergone breast implantation. Its cause and, accordingly, treatment and prevention remain to be elucidated fully. The aim of this prospective observational pilot study was to test the hypothesis that the presence of bacteria on breast implants is associated with capsular contracture. We prospectively studied consecutive patients who underwent breast implant removal for reasons other than overt infection at the Mayo Clinic from February through September 2008. Removed breast implants were processed using a vortexing/sonication procedure and then subjected to semiquantitative culture. Twenty-seven of the 45 implants collected were removed due to significant capsular contracture, among which 9 (33%) had ≥20 CFU bacteria/10 ml sonicate fluid; 18 were removed for reasons other than significant capsular contracture, among which 1 (5%) had ≥20 CFU/10 ml sonicate fluid (P = 0.034). Propionibacterium species, coagulase-negative staphylococci, and Corynebacterium species were the microorganisms isolated. The results of this study demonstrate that there is a significant association between capsular contracture and the presence of bacteria on the implant. The role of these bacteria in the pathogenesis of capsular contracture deserves further study.

Microbiologic activity in laser resurfacing plume and debris

Background and Objective: With the increasing use of laser resurfacing, concerns have arisen about the biological hazards associated with the procedure. This study analyzed the potential bacterial and viral exposure to operating room personnel as a result of the laser smoke plume in CO2 laser resurfacing.

Norian Craniofacial Repair System bone cement for the Repair of Craniofacial skeletal defects

Purpose To describe the use of the Norian Craniofacial Repair System (CRS) calcium phosphate bone cement in the restoration of craniofacial skeletal defects. Methods Consecutive case series. Results Calcium phosphate bone cement was used to repair craniofacial skeletal defects in three patients. Indications included repair of a posttraumatic orbital floor defect causing hypo-ophthalmos, reconstruction of frontal craniotomy and temporalis muscle donor sites in a patient who had undergone resection of an invasive squamous cell carcinoma, and augmentation of a post-traumatic anterior maxillary skeletal defect. The primary outcome measure was the restoration of bony volume and support. The use of calcium phosphate bone cement in these patients was effective and without complications. Conclusions Norian CRS calcium phosphate bone cement is useful in the repair of craniofacial skeletal defects.

Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC®) dressing for irradiated extremity sarcoma defects

BackgroundFlaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds.MethodsThe records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC® therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes.ResultsSTSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% – 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures.ConclusionAlthough flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.

Treatment outcome for 424 primary cases of clinical stage I cutaneous malignant melanoma of the head and neck

Cutaneous malignant melanoma (CMM) is increasing in frequency. Surgery remains the primary and only curative treatment method. Our aim was to define prognostic factors and outcome predictors for patients with clinical stage I CMM of the head and neck.

Familial gigantiform cementoma.

Familial gigantiform cementoma is a rare autosomal dominant tumor that is benign but can result in disfigurement of the facial skeleton. Two families with a total of five patients presented for treatment. Because of a lack of opportunity to obtain treatment early, three of the patients presented in adult life with massive tumors requiring extensive resection and complex reconstruction in multiple stages. The two female patients had chronic anemia caused by multifocal polypoid adenomas of the uterus and required hysterectomy before treatment. The last three patients had elevated alkaline phosphatase levels before tumor resection, and these levels decreased after surgery. With extensive resection of the tumors and reconstruction of both the soft tissues and facial skeleton, good functional and aesthetic results can be obtained. There has been no tumor recurrence with 3 years of follow-up.

Tissue expansion-assisted closure of massive ventral hernias.

Many multitrauma and severely ill patients requiring multiple laparotomies survive because of advanced critical care and aggressive management, but often these patients face severe challenges on their path to recovery. Prolonged operations and consequential fluid shifts make abdominal closure impossible and even detrimental because of abdominal compartment syndrome, and laparotomy wounds often remain open. As a result, a relative loss of abdominal domain from tissue contraction or actual loss from tumor resection and debridement can occur. Regardless of the cause, abdominal viscera must be contained, usually with an absorbable mesh followed by a split thickness skin graft (STSG). Repair of the resultant ventral hernia is done electively. These large midline hernias pose a great challenge to reconstruction. Primary repair of incisional hernias has a reported recurrence rate between 40% and 46%. Many methods such as primary closure, mesh repair, component separation, tissue expansion, pedicled flap, and free flap have been proposed. Rohrich and colleagues offer an excellent discussion of all available options. We review our experience with large hernia repair by tissue expansion of the remaining abdominal wall tissue.