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Necrotizing soft tissue infection masquerading as cutaneous abcess following illicit drug injection
48.5
CURRENT LITERATURE recurrence group.-T.
in the BCNS group, but not in the non-BCNS NAKAJIMA
Reprint requests to Dr Shigematsu: Second Department of Oral and Maxillofacial Surgery, Eikai University, School of Dentistry, 1-1, Keyakidai, Sakato City, 350-0248 Japan.
Necrotizing Soft Tissue Infection Masquerading as Cutaneous Abcess Following Illicit Drug Injection. Callahan T, Schecter W, Horn J. Arch Surg 133:812,1998 Necrotizing soft-tissue infection (NSTI) is an uncommon pathology associated with a high rate of morbidity and mortality. The lack of clear boundaries and the extreme virulence of the microorganism responsible for this infection have been proposed as the causes of the high mortality rate. Another characteristic of this pathology is the lack of a pathonogmonic clinical presentation and the benign appearance of the overlying skin which deceptively mask the severe tissue destruction that lies beneath the surface. In the last 5 years, an increased number of cases of NSTI have been reported associated with individuals with a history of intravenous drug use (,IVDU). In those cases, the NSTI sometimes is masqueraded as cutaneous abscess. This study was designed to assess the clinical presentation and the possible factors associated with NSTI in intravenous drug users (lVDUs). Between January 1992 and July 1997, 3560 patients at San Francisco General Hospital underwent lncision and drainage of subcutaneous abscess as a conscience of IVDU. Of this group, 30 IVDUs required debridement for NSTI diagnosed during the incision and drainage procedure. In terms of clinical presentation, all 30 cases presented with some combination of fluctuance, erythema, or indurationall signs common to the subcutaneous abscess. Pain used as a criterion in diagnosing of NSTI, is a normal finding in the IVDUs around the area of injection. Only 5 of 30 patients had physical findings suggestive of NSTI such as crepitance, skin necrosis, or bullae. Radiological studies were not diagnostic for NSTI. Irregular findings of the fascial tissues, such as thickening and fluid accumulation consistent with NSTI can be observed in ultrasound and magnetic resonance imaging studies. Fifty-nine percent of the cases were product of a multiple microorganism infection. Clostridium Perfingens was associated with a higher rate of mortality. The most common microorganism isolated was the Staphylococcus. The group A Streptococci was isolated in several cultures and its presence is associated with a more benign outcome, a longer time of evolution before a possible diagnosis, and a lower frequency of septic shock and mortality in the IVDU patients. The rate of mortality in this series was 20%. Fifteen percent were early deaths caused by septic shock and 55 were late deaths from multiorgan failure. -A. HERRERA Reprints request to Dr Horn: San Francisco Department of Surgery, 3E, 1001 Potero Ave, 94110.
General Hospital, San Francisco, CA
Neurotmesis of the Lateral Femoral Cutaneous Nerve When Coring for Iliac Crest Bone Grafts. van den Broecke DG, Schuurman AH, Borg ED, et al. Plast Reconstr Surg 102:1163,1998 Autogenous cancellous bone grafts from the iliac crest are frequently obtained for the purpose of bone fusion and
reconstruction. The development of a coring technique was introduced in the mid-1980s and advantages of this technique as compared with traditional bone graft techniques include small skin incision (1 to 2 cm), better cosmetic results, less pain, shorter hospital stay, early ambulation, and decreased donor site morbidity. This article describes two case reports of injury to the lateral femoral cutaneous nerve during harvest of iliac crest bone graft via this technique. Neurotemesis of this nerve causes a clinical condition known as meralgia paresthetica where patients complain of a dull ache, burning sensation, tingling, or numbness of the anterolateral aspect of the thigh. Recommendations by the authors to avoid this complication include placement of incision parallel to and just below the level of the iliac crest and to place the incision some 5 to 8 cm posterior to the anterior superior iliac crest. Dissection down to the crest should be blunt and just lateral to the anterior aspect of the crest. If these recommendations are followed the authors feel that this complication can be minimized.-J. BROKLOFF Reprint requests to Dr Schuurman: Department of Plastic Surgery, University Hospital Utrecht PO Box 85500, 3508 GA Utrecht, The Netherlands.
Soft-Palate Reconstruction With a “Scarf’ Superior Constrictor Advancement Rotation Flap. Zeitels SM, Rim J. Laryngoscope 108:1136,1998 Reconstruction of hem&soft-palate defects after tumor resection is usually performed by means of a regional flap, free-tissue transfer, or a prosthesis. Because of the technical difticulties of standard surgical reconstruction, soft-palate defects are more frequently managed by means of oral prostheses. Palatal obturators are cumbersome to wear and are a compromised solution to natural soft tissue. The author describes the myomucosal superior constrictor advancement
rotation
flap (SCARF),
emphasizing
its technical
simplicity and effectiveness for reconstruction of the velopharynx after hemi-soft-palate excision. From 1991 to 1996, 10 patients underwent resection of a tumor of the soft palate and/or tonsil in which 35% to 65% of the soft palate was removed. The resultant defect in all cases was transmural and would have resulted in gross velopharyngeal incompetence if left to heal by secondary intention. The SCARF can be performed transorally and results in a dynamic neopharynx, because local tissues are used. By suturing the transected edge of the soft palate to the transected edge of the superior constrictor in the posterior pharyngeal wall, a circumferential muscular valve is re-established. Because fibers of the superior constrictor run anteriorly through the soft palate, suturing the residual hemi-soft palate to the superior constrictor in the posterior pharyngeal wall defect results in a neovelopharynx that functions similarly to the normal velopharynx. All patients in this study re-established normal velopharyngeal function without significant phonatory or deglutitive disability. Two patients did require a second-stage reinforcement of the suture line after partial dehiscence. According to the authors, the SCARF reconstruction of the soft palate is simple, fast, and reliable and there is no significant donor site morbidity.-H. PATINO Reprint requests to Dr Zeitels: Department ogy, Massachusetts Eye and Ear Infirmary, MA02114.
of Otology and Laryngol243 Charles St, Boston,
CURRENT LITERATURE recurrence group.-T.
in the BCNS group, but not in the non-BCNS NAKAJIMA
Reprint requests to Dr Shigematsu: Second Department of Oral and Maxillofacial Surgery, Eikai University, School of Dentistry, 1-1, Keyakidai, Sakato City, 350-0248 Japan.
Necrotizing Soft Tissue Infection Masquerading as Cutaneous Abcess Following Illicit Drug Injection. Callahan T, Schecter W, Horn J. Arch Surg 133:812,1998 Necrotizing soft-tissue infection (NSTI) is an uncommon pathology associated with a high rate of morbidity and mortality. The lack of clear boundaries and the extreme virulence of the microorganism responsible for this infection have been proposed as the causes of the high mortality rate. Another characteristic of this pathology is the lack of a pathonogmonic clinical presentation and the benign appearance of the overlying skin which deceptively mask the severe tissue destruction that lies beneath the surface. In the last 5 years, an increased number of cases of NSTI have been reported associated with individuals with a history of intravenous drug use (,IVDU). In those cases, the NSTI sometimes is masqueraded as cutaneous abscess. This study was designed to assess the clinical presentation and the possible factors associated with NSTI in intravenous drug users (lVDUs). Between January 1992 and July 1997, 3560 patients at San Francisco General Hospital underwent lncision and drainage of subcutaneous abscess as a conscience of IVDU. Of this group, 30 IVDUs required debridement for NSTI diagnosed during the incision and drainage procedure. In terms of clinical presentation, all 30 cases presented with some combination of fluctuance, erythema, or indurationall signs common to the subcutaneous abscess. Pain used as a criterion in diagnosing of NSTI, is a normal finding in the IVDUs around the area of injection. Only 5 of 30 patients had physical findings suggestive of NSTI such as crepitance, skin necrosis, or bullae. Radiological studies were not diagnostic for NSTI. Irregular findings of the fascial tissues, such as thickening and fluid accumulation consistent with NSTI can be observed in ultrasound and magnetic resonance imaging studies. Fifty-nine percent of the cases were product of a multiple microorganism infection. Clostridium Perfingens was associated with a higher rate of mortality. The most common microorganism isolated was the Staphylococcus. The group A Streptococci was isolated in several cultures and its presence is associated with a more benign outcome, a longer time of evolution before a possible diagnosis, and a lower frequency of septic shock and mortality in the IVDU patients. The rate of mortality in this series was 20%. Fifteen percent were early deaths caused by septic shock and 55 were late deaths from multiorgan failure. -A. HERRERA Reprints request to Dr Horn: San Francisco Department of Surgery, 3E, 1001 Potero Ave, 94110.
General Hospital, San Francisco, CA
Neurotmesis of the Lateral Femoral Cutaneous Nerve When Coring for Iliac Crest Bone Grafts. van den Broecke DG, Schuurman AH, Borg ED, et al. Plast Reconstr Surg 102:1163,1998 Autogenous cancellous bone grafts from the iliac crest are frequently obtained for the purpose of bone fusion and
reconstruction. The development of a coring technique was introduced in the mid-1980s and advantages of this technique as compared with traditional bone graft techniques include small skin incision (1 to 2 cm), better cosmetic results, less pain, shorter hospital stay, early ambulation, and decreased donor site morbidity. This article describes two case reports of injury to the lateral femoral cutaneous nerve during harvest of iliac crest bone graft via this technique. Neurotemesis of this nerve causes a clinical condition known as meralgia paresthetica where patients complain of a dull ache, burning sensation, tingling, or numbness of the anterolateral aspect of the thigh. Recommendations by the authors to avoid this complication include placement of incision parallel to and just below the level of the iliac crest and to place the incision some 5 to 8 cm posterior to the anterior superior iliac crest. Dissection down to the crest should be blunt and just lateral to the anterior aspect of the crest. If these recommendations are followed the authors feel that this complication can be minimized.-J. BROKLOFF Reprint requests to Dr Schuurman: Department of Plastic Surgery, University Hospital Utrecht PO Box 85500, 3508 GA Utrecht, The Netherlands.
Soft-Palate Reconstruction With a “Scarf’ Superior Constrictor Advancement Rotation Flap. Zeitels SM, Rim J. Laryngoscope 108:1136,1998 Reconstruction of hem&soft-palate defects after tumor resection is usually performed by means of a regional flap, free-tissue transfer, or a prosthesis. Because of the technical difticulties of standard surgical reconstruction, soft-palate defects are more frequently managed by means of oral prostheses. Palatal obturators are cumbersome to wear and are a compromised solution to natural soft tissue. The author describes the myomucosal superior constrictor advancement
rotation
flap (SCARF),
emphasizing
its technical
simplicity and effectiveness for reconstruction of the velopharynx after hemi-soft-palate excision. From 1991 to 1996, 10 patients underwent resection of a tumor of the soft palate and/or tonsil in which 35% to 65% of the soft palate was removed. The resultant defect in all cases was transmural and would have resulted in gross velopharyngeal incompetence if left to heal by secondary intention. The SCARF can be performed transorally and results in a dynamic neopharynx, because local tissues are used. By suturing the transected edge of the soft palate to the transected edge of the superior constrictor in the posterior pharyngeal wall, a circumferential muscular valve is re-established. Because fibers of the superior constrictor run anteriorly through the soft palate, suturing the residual hemi-soft palate to the superior constrictor in the posterior pharyngeal wall defect results in a neovelopharynx that functions similarly to the normal velopharynx. All patients in this study re-established normal velopharyngeal function without significant phonatory or deglutitive disability. Two patients did require a second-stage reinforcement of the suture line after partial dehiscence. According to the authors, the SCARF reconstruction of the soft palate is simple, fast, and reliable and there is no significant donor site morbidity.-H. PATINO Reprint requests to Dr Zeitels: Department ogy, Massachusetts Eye and Ear Infirmary, MA02114.
of Otology and Laryngol243 Charles St, Boston,