286
Correspondence and communications
References
Figure 1
Incised right ring finger with lipoma in situ.
six cases and occasional episodes of local paraesthesia in three. Functional problems were reported in 16 cases. Moreover, both hands were affected almost equally: 12 cases on the left and 15 on the right. The index and middle fingers were the most commonly involved digits, with 16 and 11 cases respectively. Eighteen cases had pre-surgical investigations, the most popular including: X-ray (11 cases), USS (six) and MRI (four). In all cases, lipomata were excised without complications and the diagnosis was confirmed by microscopic analysis revealing a collection of mature adipocytes lobulated by thin fibrous tissue septae. There were no recurrences reported and the average follow up was 33 months. Compared to the pooled reports, our case fits within the milder spectrum of lipoma presentation: a 60-year-old lady with a three-month history of an asymptomatic swelling on a small area on the dorsal aspect of the proximal phalanx of her right ring finger (one of the least reported fingers) which had the effect of impeding her from wearing jewellery. On examination, the 1 cm diameter swelling was highly mobile, soft and fluctuant. The differential diagnoses, which did not include lipoma, were: ganglion cyst, inclusion cyst or giant cell tumour. In contrast with most of the reported cases, our patient did not undergo any investigation previous to the excisional biopsy (Figure 1). Macroscopically, it was a homogenous yellow tissue of 9 mm diameter. Microscopically, the histology report confirmed a benign lipoma with no atypical features. There was no recurrence 2 years post surgery. Our case together with the more than 30 reported cases of digit lipomata highlight the importance of considering it as a differential diagnosis for benign soft tissue swelling of the digits. This is especially true for painless swellings of the index and middle finger, as these are the most common finger locations for lipomata, based on our review.
1. Kitagawa Y, Tamai K, Kim Y, Hayashi M, Makino A, Takai S. Lipoma of the finger with bone erosion. J Nippon Med Sch 2012; 79(4):307e11. 2. Abkari I, Abidi AE, Latifi M. Giant lipoma of the third finger: a case report. Chir Main 2011 Apr;30(2):152e4. 3. Khan PS, Hayat H. Lipoma of the middle finger hampering its movements. J Hand Microsurg 2011 Jun;3(1):42e3. 4. Hasham S, Burke FD. Diagnosis and treatment of swellings in the hand. Postgrad Med J 2007 May;83(979):296e300. 5. Ramirez-Montano L, Lopez RP, Ortiz NS. Giant lipoma of the third finger of the hand. SpringerPlus 2013;2(1):164. 6. Nascimento C, Barreto J, Cury Filho M. Case for diagnosis. An Bras Dermatol 2012;87(2). 7. Gupta A, Singal R, Mittal A, Goyal M. Report of two cases of subcutaneous lipoma over the finger and review of literature: case series: benign tumour. Musculoskelet Surg 2011 Dec; 95(3):247e9. 8. Yoon S, Jung SN. Lipoma of the finger presenting as restricted motion. Indian J Plastic Surg 2008 Jul;41(2):237e8. 9. Phalen GS, Kendrick JI, Rodriquez JM. Lipomas of the upper extremity. Plast Reconstr Surg 1971 November;48(5):512.
Martha F.I. De La Cruz Monroy Piyush Durani Graham J. Offer Department of Plastic and Reconstructive Surgery, University Hospitals Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK E-mail addresses: [email protected], [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.029
Combined use of fenestrated-type artificial dermis and topical negative-pressure wound therapy to treat the complex wound in the lower leg*
Dear Sir,
Funding None.
Conflict of interest None.
Bilayered artificial dermis composed of a upper silicone sheet and a lower layer of collagen sponge has been used in clinical practice for the treatment of full-thickness skin * This work was presented at the 18th Meeting of the Japan Society for Innovative Techniques in Plastic Surgery on 23/2/2013 and the 57th Annual Meeting of the Japan Society of Plastic and Reconstructive Surgeons on 11/4/2014.
Correspondence and communications defects and skin ulcers since the 1990s.1 However, the artificial dermis is not resistant to infection before capillaries have infiltrated the collagen sponge. Therefore, it is difficult to apply artificial dermis to chronic ulcers, such as decubitus, diabetic and leg ulcers, because of the relatively high incidence of infection.2 These days, artificial dermis is used in combination with NPWT (negative-pressure wound therapy) and has been reported to accelerate the formation of dermis-like tissue.3 This is mainly because the negative pressure fixes and immobilizes the artificial dermis tightly to the wound bed. Unmeshed artificial dermis has been commonly used in this combination therapy.3 A fenestrated-type artificial dermis, which features fenestration of its silicone sheet, was released recently and it adheres tightly to the wound bed, and hematoma and exudate can be removed promptly through the fenestration. This fenestrated type will be suitable in combination therapy because the negative pressure directly stimulates the proliferation of fibroblasts and endothelial cells into the collagen layer from wound beds through the fenestration of the silicone layer. We present a case of a complex circumferential wound in a lower extremity with exposed bone and tendon treated with the fenestrated-type artificial dermis and NPWT. We used the “grip tape technique” to apply polyurethane foam. After debridement, the fenestrated-type artificial dermis (Pelanc, Gunze Ltd., Ayabe, Japan) was placed and sutured to the marginal skin. The polyurethane foam of NPWT (V.A.C. therapy, KCI, Japan) was cut into a long strip about 1 cm in height and wound around the entire circumference of the lower extremity as grip tape. Mesh skin grafting in combination with NPWT was also performed after the formation of dermislike tissue in this case.
Case history A 77-year-old man with atrial fibrillation and right lower limb paresis after cerebral infarction had skin necrosis of the entire circumference of the right lower limb and right toes due to cellulitis of Acinetobacter and group G bStreptococcus. After the control of infection, necrotic tissues were debrided and tendons, metatarsals and tibia bone were exposed (Figure 1:Left). Fenestrated-type Pelnac was applied and sutured (Figure 1:Right). No sign of infection was observed for 5 days after application and NPWT using the grip tape technique was started at 100 mmHg (Figure 2:Left). The strip was changed once a week. After removal of the silicone sheet on day 16 after NPWT, good dermis-like tissue was formed on the wound bed, including exposed bone and tendon. A 3-fold meshskin graft was applied and fixated by NPWT using the grip tape method. NPWT was continued for 7 days and the skin graft took almost completely. The epithelialization was completed 15 days after grafting and no recurrence was observed 3 months after grafting (Figure 2:Right). The combination therapy of dermal substitutes and NPWT has been reported to be effective in the treatment of chronic ulcers and complex wounds with exposed tendon or bone.3 Regarding this combination therapy, unmeshed artificial dermis has been used commonly;
287
Figure 1 Time course of a 77-year-old man with skin necrosis of the entire circumference of the right lower limb and right toes due to cellulitis. Left: Tendons, metatarsals and tibia bone were exposed after debridement. Right: The fenestratedtype artificial dermis was placed and sutured.
however, meshed artificial dermis would be suitable, especially in complex wounds and those with a large circumference. In our case, dermis-like tissue formed promptly and the skin graft took almost completely, even in the complex wound. We confirmed that the formation of dermis-like tissue and capillary formation were accelerated beneath the slit of the silicone sheet histologically in another case. As for the mechanism behind the effectiveness of artificial dermis and NPWT, Baldwin et al. reported that continuous negative pressure stimulates the migration and proliferation of human microvascular endothelial cells cultured on artificial dermis (Integra, Integra LifeSciences, NJ, US) through stabs of the silicone layer.4 In clinical cases, Fraccalvieri used meshed artificial dermis in combination with NPWT with the aim of allowing drainage of wound exudates and to prevent hematoma formation under the silicone sheet.5 He reported that NPWT shortened the time to dermis-like tissue formation after the application of meshed artificial dermis and that there was a good take rate of meshed skin graft with the same level of sub-atmospheric pressure. The “grip tape technique” is our original technique to apply polyurethane foam easily to the entire surface of a
288
Correspondence and communications 2. Morimoto N, Yoshimura K, Niimi M, et al. Novel collagen/ gelatin scaffold with sustained release of basic fibroblast growth factor: clinical trial for chronic skin ulcers. Tissue Eng Part A 2013 Sep;19(17e18):1931e40. 3. Moiemen Naiem S. Topical negative pressure therapy: does it accelerate neovascularisation within the dermal regeneration template, Integra? A prospective histological in vivo study. Burns 2010 Sep;36(6):764e8. 4. Baldwin C, Potter M, Clayton E, Irvine L, Dye J. Topical negative pressure stimulates endothelial migration and proliferation: a suggested mechanism for improved integration of Integra. Ann Plast Surg 2009 Jan;62(1):92e6. 5. Fraccalvieri M, Pristera ` G, Zingarelli E, Ruka E, Bruschi S. Treatment of chronic heel osteomyelitis in vasculopathic patients. Can the combined use of Integra, skin graft and negative pressure wound therapy be considered a valid therapeutic approach after partial tangential calcanectomy? Int Wound J 2012 Apr;9(2):214e20.
Atsuyuki Kuro Department of Plastic and Reconstructive Surgery, Kansai Medical University, Takii Hospital, Japan E-mail address: [email protected]
Figure 2 Left: Our “grip tape technique”: A long strip of polyurethane foam was wound around the entire circumference of the lower extremity after application of the fenestrated-type artificial dermis. Right: No recurrence was observed 3 months after grafting.
lower extremity. Recently, V.A.C. Simplace EX Foam was developed and shown to be potentially useful for this technique because it was already cut in a circular manner. Our case showed that fenestrated-type artificial dermis in combination with NPWT obtained good results in the treatment of the complex wound. The “grip tape technique” was useful in the application of NPWT, especially over the entire circumference of the leg.
Funding N/A.
Ethical approval N/A.
Conflict of interest None.
References 1. Yannas IV, Orgill DP, Burke JF. Template for skin regeneration. Plast Reconstr Surg ;127 Suppl. 1:60Se70S. [Review].
Naoki Morimoto Miyuki Ueda Ai Horiuchi Takashi Yamauchi Department of Plastic and Reconstructive Surgery, Kansai Medical University, Hirakata Hospital, Japan E-mail address: [email protected] Michiharu Sakamoto Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Japan Kenji Suzuki Department of Plastic and Reconstructive Surgery, Kansai Medical University, Takii Hospital, Japan Kenji Kusumoto Department of Plastic and Reconstructive Surgery, Kansai Medical University, Hirakata Hospital, Japan ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.048
Re: Toxic epidermal necrolysis (TEN): The Chelsea and Westminster hospital wound management algorithm Dear Sir, We read the article by Abela et al.1 with much interest and they are to be congratulated for their proposed TEN wound management algorithm. This is in view of the fact
Correspondence and communications
References
Figure 1
Incised right ring finger with lipoma in situ.
six cases and occasional episodes of local paraesthesia in three. Functional problems were reported in 16 cases. Moreover, both hands were affected almost equally: 12 cases on the left and 15 on the right. The index and middle fingers were the most commonly involved digits, with 16 and 11 cases respectively. Eighteen cases had pre-surgical investigations, the most popular including: X-ray (11 cases), USS (six) and MRI (four). In all cases, lipomata were excised without complications and the diagnosis was confirmed by microscopic analysis revealing a collection of mature adipocytes lobulated by thin fibrous tissue septae. There were no recurrences reported and the average follow up was 33 months. Compared to the pooled reports, our case fits within the milder spectrum of lipoma presentation: a 60-year-old lady with a three-month history of an asymptomatic swelling on a small area on the dorsal aspect of the proximal phalanx of her right ring finger (one of the least reported fingers) which had the effect of impeding her from wearing jewellery. On examination, the 1 cm diameter swelling was highly mobile, soft and fluctuant. The differential diagnoses, which did not include lipoma, were: ganglion cyst, inclusion cyst or giant cell tumour. In contrast with most of the reported cases, our patient did not undergo any investigation previous to the excisional biopsy (Figure 1). Macroscopically, it was a homogenous yellow tissue of 9 mm diameter. Microscopically, the histology report confirmed a benign lipoma with no atypical features. There was no recurrence 2 years post surgery. Our case together with the more than 30 reported cases of digit lipomata highlight the importance of considering it as a differential diagnosis for benign soft tissue swelling of the digits. This is especially true for painless swellings of the index and middle finger, as these are the most common finger locations for lipomata, based on our review.
1. Kitagawa Y, Tamai K, Kim Y, Hayashi M, Makino A, Takai S. Lipoma of the finger with bone erosion. J Nippon Med Sch 2012; 79(4):307e11. 2. Abkari I, Abidi AE, Latifi M. Giant lipoma of the third finger: a case report. Chir Main 2011 Apr;30(2):152e4. 3. Khan PS, Hayat H. Lipoma of the middle finger hampering its movements. J Hand Microsurg 2011 Jun;3(1):42e3. 4. Hasham S, Burke FD. Diagnosis and treatment of swellings in the hand. Postgrad Med J 2007 May;83(979):296e300. 5. Ramirez-Montano L, Lopez RP, Ortiz NS. Giant lipoma of the third finger of the hand. SpringerPlus 2013;2(1):164. 6. Nascimento C, Barreto J, Cury Filho M. Case for diagnosis. An Bras Dermatol 2012;87(2). 7. Gupta A, Singal R, Mittal A, Goyal M. Report of two cases of subcutaneous lipoma over the finger and review of literature: case series: benign tumour. Musculoskelet Surg 2011 Dec; 95(3):247e9. 8. Yoon S, Jung SN. Lipoma of the finger presenting as restricted motion. Indian J Plastic Surg 2008 Jul;41(2):237e8. 9. Phalen GS, Kendrick JI, Rodriquez JM. Lipomas of the upper extremity. Plast Reconstr Surg 1971 November;48(5):512.
Martha F.I. De La Cruz Monroy Piyush Durani Graham J. Offer Department of Plastic and Reconstructive Surgery, University Hospitals Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK E-mail addresses: [email protected], [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.029
Combined use of fenestrated-type artificial dermis and topical negative-pressure wound therapy to treat the complex wound in the lower leg*
Dear Sir,
Funding None.
Conflict of interest None.
Bilayered artificial dermis composed of a upper silicone sheet and a lower layer of collagen sponge has been used in clinical practice for the treatment of full-thickness skin * This work was presented at the 18th Meeting of the Japan Society for Innovative Techniques in Plastic Surgery on 23/2/2013 and the 57th Annual Meeting of the Japan Society of Plastic and Reconstructive Surgeons on 11/4/2014.
Correspondence and communications defects and skin ulcers since the 1990s.1 However, the artificial dermis is not resistant to infection before capillaries have infiltrated the collagen sponge. Therefore, it is difficult to apply artificial dermis to chronic ulcers, such as decubitus, diabetic and leg ulcers, because of the relatively high incidence of infection.2 These days, artificial dermis is used in combination with NPWT (negative-pressure wound therapy) and has been reported to accelerate the formation of dermis-like tissue.3 This is mainly because the negative pressure fixes and immobilizes the artificial dermis tightly to the wound bed. Unmeshed artificial dermis has been commonly used in this combination therapy.3 A fenestrated-type artificial dermis, which features fenestration of its silicone sheet, was released recently and it adheres tightly to the wound bed, and hematoma and exudate can be removed promptly through the fenestration. This fenestrated type will be suitable in combination therapy because the negative pressure directly stimulates the proliferation of fibroblasts and endothelial cells into the collagen layer from wound beds through the fenestration of the silicone layer. We present a case of a complex circumferential wound in a lower extremity with exposed bone and tendon treated with the fenestrated-type artificial dermis and NPWT. We used the “grip tape technique” to apply polyurethane foam. After debridement, the fenestrated-type artificial dermis (Pelanc, Gunze Ltd., Ayabe, Japan) was placed and sutured to the marginal skin. The polyurethane foam of NPWT (V.A.C. therapy, KCI, Japan) was cut into a long strip about 1 cm in height and wound around the entire circumference of the lower extremity as grip tape. Mesh skin grafting in combination with NPWT was also performed after the formation of dermislike tissue in this case.
Case history A 77-year-old man with atrial fibrillation and right lower limb paresis after cerebral infarction had skin necrosis of the entire circumference of the right lower limb and right toes due to cellulitis of Acinetobacter and group G bStreptococcus. After the control of infection, necrotic tissues were debrided and tendons, metatarsals and tibia bone were exposed (Figure 1:Left). Fenestrated-type Pelnac was applied and sutured (Figure 1:Right). No sign of infection was observed for 5 days after application and NPWT using the grip tape technique was started at 100 mmHg (Figure 2:Left). The strip was changed once a week. After removal of the silicone sheet on day 16 after NPWT, good dermis-like tissue was formed on the wound bed, including exposed bone and tendon. A 3-fold meshskin graft was applied and fixated by NPWT using the grip tape method. NPWT was continued for 7 days and the skin graft took almost completely. The epithelialization was completed 15 days after grafting and no recurrence was observed 3 months after grafting (Figure 2:Right). The combination therapy of dermal substitutes and NPWT has been reported to be effective in the treatment of chronic ulcers and complex wounds with exposed tendon or bone.3 Regarding this combination therapy, unmeshed artificial dermis has been used commonly;
287
Figure 1 Time course of a 77-year-old man with skin necrosis of the entire circumference of the right lower limb and right toes due to cellulitis. Left: Tendons, metatarsals and tibia bone were exposed after debridement. Right: The fenestratedtype artificial dermis was placed and sutured.
however, meshed artificial dermis would be suitable, especially in complex wounds and those with a large circumference. In our case, dermis-like tissue formed promptly and the skin graft took almost completely, even in the complex wound. We confirmed that the formation of dermis-like tissue and capillary formation were accelerated beneath the slit of the silicone sheet histologically in another case. As for the mechanism behind the effectiveness of artificial dermis and NPWT, Baldwin et al. reported that continuous negative pressure stimulates the migration and proliferation of human microvascular endothelial cells cultured on artificial dermis (Integra, Integra LifeSciences, NJ, US) through stabs of the silicone layer.4 In clinical cases, Fraccalvieri used meshed artificial dermis in combination with NPWT with the aim of allowing drainage of wound exudates and to prevent hematoma formation under the silicone sheet.5 He reported that NPWT shortened the time to dermis-like tissue formation after the application of meshed artificial dermis and that there was a good take rate of meshed skin graft with the same level of sub-atmospheric pressure. The “grip tape technique” is our original technique to apply polyurethane foam easily to the entire surface of a
288
Correspondence and communications 2. Morimoto N, Yoshimura K, Niimi M, et al. Novel collagen/ gelatin scaffold with sustained release of basic fibroblast growth factor: clinical trial for chronic skin ulcers. Tissue Eng Part A 2013 Sep;19(17e18):1931e40. 3. Moiemen Naiem S. Topical negative pressure therapy: does it accelerate neovascularisation within the dermal regeneration template, Integra? A prospective histological in vivo study. Burns 2010 Sep;36(6):764e8. 4. Baldwin C, Potter M, Clayton E, Irvine L, Dye J. Topical negative pressure stimulates endothelial migration and proliferation: a suggested mechanism for improved integration of Integra. Ann Plast Surg 2009 Jan;62(1):92e6. 5. Fraccalvieri M, Pristera ` G, Zingarelli E, Ruka E, Bruschi S. Treatment of chronic heel osteomyelitis in vasculopathic patients. Can the combined use of Integra, skin graft and negative pressure wound therapy be considered a valid therapeutic approach after partial tangential calcanectomy? Int Wound J 2012 Apr;9(2):214e20.
Atsuyuki Kuro Department of Plastic and Reconstructive Surgery, Kansai Medical University, Takii Hospital, Japan E-mail address: [email protected]
Figure 2 Left: Our “grip tape technique”: A long strip of polyurethane foam was wound around the entire circumference of the lower extremity after application of the fenestrated-type artificial dermis. Right: No recurrence was observed 3 months after grafting.
lower extremity. Recently, V.A.C. Simplace EX Foam was developed and shown to be potentially useful for this technique because it was already cut in a circular manner. Our case showed that fenestrated-type artificial dermis in combination with NPWT obtained good results in the treatment of the complex wound. The “grip tape technique” was useful in the application of NPWT, especially over the entire circumference of the leg.
Funding N/A.
Ethical approval N/A.
Conflict of interest None.
References 1. Yannas IV, Orgill DP, Burke JF. Template for skin regeneration. Plast Reconstr Surg ;127 Suppl. 1:60Se70S. [Review].
Naoki Morimoto Miyuki Ueda Ai Horiuchi Takashi Yamauchi Department of Plastic and Reconstructive Surgery, Kansai Medical University, Hirakata Hospital, Japan E-mail address: [email protected] Michiharu Sakamoto Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Japan Kenji Suzuki Department of Plastic and Reconstructive Surgery, Kansai Medical University, Takii Hospital, Japan Kenji Kusumoto Department of Plastic and Reconstructive Surgery, Kansai Medical University, Hirakata Hospital, Japan ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.048
Re: Toxic epidermal necrolysis (TEN): The Chelsea and Westminster hospital wound management algorithm Dear Sir, We read the article by Abela et al.1 with much interest and they are to be congratulated for their proposed TEN wound management algorithm. This is in view of the fact
