- Email: [email protected]
Postoperative donor-site mucormycosis after fibula flap harvest
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Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 49 (2011) 157–159
use to remove strong odours but does not specifically mention chlorhexidine, however Lucht et al.2 suggest dipping leeches in a chlorhexidine solution before application to reduce infection rates. It has left us wondering that we may suspect leech therapy is of no further benefit, where in fact they just do not like chlorhexidine. We would be interested to hear if any other units have made a similar observation.
Conflict of interest None. References 1. www.biopharm-leeches.com. 2. Lucht F, Aubert G, Seguin P, Tissot-Gueraz F, Relave M. Post-operative skin-flap decongestion, leeches and Aeromonas hydrophila. J Hosp Infect 1988;11:92–3.
Jennifer Wylie ∗ SpR Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom Wendy Matthews SHO Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom A. Nicholas Brown StR Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom ∗ Corresponding author. E-mail addresses: [email protected] (J. Wylie), wendy [email protected] (W. Matthews), [email protected] (A.N. Brown)
extremity was fitted with a compression bandage and a brace to ensure complete immobilisation. The donor site was inspected daily and noted to be clean and dry, but on day 16 a slightly necrotic area with a dark eschar was noted in the skin graft, which was debrided immediately. There was a deep area of necrotic tissue with invasion of the underlying peroneus longus and soleus muscles. From then on, the surgical wound was debrided daily and had improved considerably by the third day (Fig. 1). The wound healed well and was covered with a skin graft at 2 weeks. Microscopic examination of the excised fasciomuscular tissue showed non-septate, irregular hyphae, and vascular invasion consistent with mucormycosis. Unfortunately, our patient was unable to lift her toes and extend her foot because of a palsy of the left peroneal nerve, of which electromyography at 6 months showed reduced stimulation. Despite physiotherapy she now has severe dysfunction of the leg that requires walking aids and severely restricts her activities of daily living. To our knowledge this is the first report of postoperative peroneal neuropathy as a complication of mucormycosis of the donor site after harvest of a fibular flap. Mucormycosis of the skin and wounds has been associated with burns, traumatic disruption of skin, persistent maceration of the skin, and use of contaminated elastic bandages.2 It can be locally invasive and penetrate from the cutaneous and subcutaneous tissues into the adjacent fat, muscle, fascia, and even bone. However, isolated mucormycosis has a favourable prognosis and a low mortality if the wound is debrided extensively and necrotic and infected tissues are resected promptly.3 In our
Available online 6 May 2010 doi:10.1016/j.bjoms.2010.04.003
Postoperative donor-site mucormycosis after fibula flap harvest Sir, We read with interest the paper by Sieg et al.1 and present an unusual case from our own experience. A 45-year-old woman had a secondary reconstruction with a left fibular free flap for restoration of a mandibular defect after resection of an oral carcinoma. She had no coexisting medical conditions such as type II diabetes. We dissected a fibular osteofasciocutaneous flap by the usual technique including 8 cm of bone and a skin paddle about 12 cm long. A tourniquet was used. The skin of the donor site was closed with a partial skin graft taken from the thigh. The donor
Fig. 1. Photograph taken at the time of debridement.
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 49 (2011) 157–159
159
case, necrosis of deep fascia and muscle by fungal infection and aggressive debridement of the wound were the main risk factors of long-term morbidity at the donor site.
References 1. Sieg P, Taner C, Hakim SG, Jacobsen HC. Long-term evaluation of donor site morbidity after free fibula transfer. Br J Oral Maxillofac Surg 2010;48:267–70. 2. Spellberg B, Edwards Jr J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation and management. Clin Microbiol Rev 2005;18:556–69. 3. Arnáiz-García ME, Alonso-Pe˜na D, González-Vela Mdel C, GarcíaPalomo JD, Sanz-Giménez-Rico JR, Arnáiz-García AM. Cutaneous mucormycosis: report of five cases and review of the literature. J Plast Reconstr Aesthet Surg 2009;62:e434–41.
P. Infante-Cossio ∗ Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain P. Gacto-Sanchez Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain E. Hens-Aumente Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain D. Sicilia-Castro Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain ∗ Corresponding author. Tel.: +34 955 01 26 08. E-mail address: [email protected] (P. Infante-Cossio) Available online 12 January 2011 doi:10.1016/j.bjoms.2010.12.004
One dog bite too far Sir, Dog bites account for 250,000 minor injury and emergency unit attendances in the UK each year. These are located on the face in over 77% of cases with the predominant areas affected being the nose, cheeks and the ear.1,2 Thus, when the patient seeks medical attention, Maxillofacial surgeons are frequently involved in their management. We have noticed an increasing number of patients presenting with facial dogbite wounds, bitten on more than one occasion. In the last year we had two patients that sustained facial wounds from their same dog twice. These have commonly involved the family pet (Fig. 1). As a specialty we are uniquely positioned
Fig. 1. 28-year-old pt. who presented with facial dog bite wound involving cheek and left ear. She had presented six months previously with partial upper lip avulsion secondary to a bite wound. Further history revealed this involved the family pet which was subsequently destroyed.
to promote prevention strategies and patient education. This role in prevention and education could be in conjunction with our Veterinary Colleagues, and would increase the profile of our specialty to the general public. We feel any opportunity to raise awareness and educate towards prevention of facial dogbite wounds and the associated facial disfigurement should be encouraged by our specialty.
Conflict of interest The authors have no conflict of interest to declare.
References 1. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds: management update. Int J Oral Maxillofac Surg 2005;34(July (5)):464–72. 2. Whyte A. Beware of the dog. Nurs Stand 2010;24(August (51)):22–3.
C. Mannion Oral and Maxillofacial Department, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8, United Kingdom A. Kanatas ∗ Oral and Maxillofacial Department, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom M.R. Telfer Oral and Maxillofacial Department, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8, United Kingdom ∗ Corresponding author. Tel.: +44 07769946105. E-mail addresses: [email protected] (C. Mannion), [email protected] (A. Kanatas), [email protected] (M.R. Telfer) Available online 13 January 2011 doi:10.1016/j.bjoms.2010.12.008
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 49 (2011) 157–159
use to remove strong odours but does not specifically mention chlorhexidine, however Lucht et al.2 suggest dipping leeches in a chlorhexidine solution before application to reduce infection rates. It has left us wondering that we may suspect leech therapy is of no further benefit, where in fact they just do not like chlorhexidine. We would be interested to hear if any other units have made a similar observation.
Conflict of interest None. References 1. www.biopharm-leeches.com. 2. Lucht F, Aubert G, Seguin P, Tissot-Gueraz F, Relave M. Post-operative skin-flap decongestion, leeches and Aeromonas hydrophila. J Hosp Infect 1988;11:92–3.
Jennifer Wylie ∗ SpR Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom Wendy Matthews SHO Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom A. Nicholas Brown StR Oral and Maxillofacial Surgery, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom ∗ Corresponding author. E-mail addresses: [email protected] (J. Wylie), wendy [email protected] (W. Matthews), [email protected] (A.N. Brown)
extremity was fitted with a compression bandage and a brace to ensure complete immobilisation. The donor site was inspected daily and noted to be clean and dry, but on day 16 a slightly necrotic area with a dark eschar was noted in the skin graft, which was debrided immediately. There was a deep area of necrotic tissue with invasion of the underlying peroneus longus and soleus muscles. From then on, the surgical wound was debrided daily and had improved considerably by the third day (Fig. 1). The wound healed well and was covered with a skin graft at 2 weeks. Microscopic examination of the excised fasciomuscular tissue showed non-septate, irregular hyphae, and vascular invasion consistent with mucormycosis. Unfortunately, our patient was unable to lift her toes and extend her foot because of a palsy of the left peroneal nerve, of which electromyography at 6 months showed reduced stimulation. Despite physiotherapy she now has severe dysfunction of the leg that requires walking aids and severely restricts her activities of daily living. To our knowledge this is the first report of postoperative peroneal neuropathy as a complication of mucormycosis of the donor site after harvest of a fibular flap. Mucormycosis of the skin and wounds has been associated with burns, traumatic disruption of skin, persistent maceration of the skin, and use of contaminated elastic bandages.2 It can be locally invasive and penetrate from the cutaneous and subcutaneous tissues into the adjacent fat, muscle, fascia, and even bone. However, isolated mucormycosis has a favourable prognosis and a low mortality if the wound is debrided extensively and necrotic and infected tissues are resected promptly.3 In our
Available online 6 May 2010 doi:10.1016/j.bjoms.2010.04.003
Postoperative donor-site mucormycosis after fibula flap harvest Sir, We read with interest the paper by Sieg et al.1 and present an unusual case from our own experience. A 45-year-old woman had a secondary reconstruction with a left fibular free flap for restoration of a mandibular defect after resection of an oral carcinoma. She had no coexisting medical conditions such as type II diabetes. We dissected a fibular osteofasciocutaneous flap by the usual technique including 8 cm of bone and a skin paddle about 12 cm long. A tourniquet was used. The skin of the donor site was closed with a partial skin graft taken from the thigh. The donor
Fig. 1. Photograph taken at the time of debridement.
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 49 (2011) 157–159
159
case, necrosis of deep fascia and muscle by fungal infection and aggressive debridement of the wound were the main risk factors of long-term morbidity at the donor site.
References 1. Sieg P, Taner C, Hakim SG, Jacobsen HC. Long-term evaluation of donor site morbidity after free fibula transfer. Br J Oral Maxillofac Surg 2010;48:267–70. 2. Spellberg B, Edwards Jr J, Ibrahim A. Novel perspectives on mucormycosis: pathophysiology, presentation and management. Clin Microbiol Rev 2005;18:556–69. 3. Arnáiz-García ME, Alonso-Pe˜na D, González-Vela Mdel C, GarcíaPalomo JD, Sanz-Giménez-Rico JR, Arnáiz-García AM. Cutaneous mucormycosis: report of five cases and review of the literature. J Plast Reconstr Aesthet Surg 2009;62:e434–41.
P. Infante-Cossio ∗ Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain P. Gacto-Sanchez Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain E. Hens-Aumente Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain D. Sicilia-Castro Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013 Sevilla, Spain ∗ Corresponding author. Tel.: +34 955 01 26 08. E-mail address: [email protected] (P. Infante-Cossio) Available online 12 January 2011 doi:10.1016/j.bjoms.2010.12.004
One dog bite too far Sir, Dog bites account for 250,000 minor injury and emergency unit attendances in the UK each year. These are located on the face in over 77% of cases with the predominant areas affected being the nose, cheeks and the ear.1,2 Thus, when the patient seeks medical attention, Maxillofacial surgeons are frequently involved in their management. We have noticed an increasing number of patients presenting with facial dogbite wounds, bitten on more than one occasion. In the last year we had two patients that sustained facial wounds from their same dog twice. These have commonly involved the family pet (Fig. 1). As a specialty we are uniquely positioned
Fig. 1. 28-year-old pt. who presented with facial dog bite wound involving cheek and left ear. She had presented six months previously with partial upper lip avulsion secondary to a bite wound. Further history revealed this involved the family pet which was subsequently destroyed.
to promote prevention strategies and patient education. This role in prevention and education could be in conjunction with our Veterinary Colleagues, and would increase the profile of our specialty to the general public. We feel any opportunity to raise awareness and educate towards prevention of facial dogbite wounds and the associated facial disfigurement should be encouraged by our specialty.
Conflict of interest The authors have no conflict of interest to declare.
References 1. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds: management update. Int J Oral Maxillofac Surg 2005;34(July (5)):464–72. 2. Whyte A. Beware of the dog. Nurs Stand 2010;24(August (51)):22–3.
C. Mannion Oral and Maxillofacial Department, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8, United Kingdom A. Kanatas ∗ Oral and Maxillofacial Department, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom M.R. Telfer Oral and Maxillofacial Department, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8, United Kingdom ∗ Corresponding author. Tel.: +44 07769946105. E-mail addresses: [email protected] (C. Mannion), [email protected] (A. Kanatas), [email protected] (M.R. Telfer) Available online 13 January 2011 doi:10.1016/j.bjoms.2010.12.008