Occlusive dressing for large soft tissue defects following soft tissue tumor excision

Background  Reconstructive surgery using pedicles or free muscle-skin flaps and skin grafting reduces wound complications and promotes favorable limb function; however, the sacrifice of normal tissue remains problematic and complicated. Occlusive dressings are widely employed for management of injuries, burns, and surgical wounds. However, their effectiveness for treating soft tissue defects following a soft tissue tumor excision has not been fully elucidated. The purpose of this study was to evaluate the effectiveness and safety of an occlusive dressing treatment method for soft tissue defects following soft tissue tumor excisions. Methods  We retrospectively reviewed eight patients (three men, five women) whose wounds were treated with polyurethane foam occlusive dressings to allow reconstruction of the soft tissue defect following soft tissue tumor excision. Their mean age was 64.5 years (range 23–83 years), and the mean size of the defect was 60.1 cm² (range 20–144 cm²). The wound was covered with a hydrophilic polyurethane dressing material. The treatment periods, incidence of complications, and ultimate outcomes were evaluated. Results  Seven defects were completely healed by secondary intention without the requirement of any additional surgery. Mean treatment periods were 21.6 weeks (range 13.5–44.0 weeks). Mean follow-up periods were 33.1 months (range 15.8–48.6 months). One patient with a recurrent malignant fibrous histiocytoma (MFH) who had a history of radiotherapy required a posterior thigh flap 44 weeks after the surgery. Recurrence due to a positive surgical margin was observed in only one patient with recurrent MFH. None of the patients exhibited clinical evidence of superficial or deep infection. Conclusions  This treatment method is simple, safe, and reliable. We concluded that the highly favorable indications of this treatment are ideal for patients who wish to avoid sacrificing their normal tissue, have no history of radiotherapy before surgery, and do not require chemotherapy or radiotherapy after the operation.     

Distal soft tissue release

The distal soft tissue release is an essential portion of the operative treatment of hallux valgus. The pathology of hallux valgus is highlighted by subluxation of both the metatarsophalangeal and metatarsosesamoid joints with concomitant contracture of the lateral capsule and soft tissue structures. The operative treatment requires an understanding of the importance of restoring the anatomic relationships about the metatarsophalangeal joint. The surgical technique of the formal distal soft tissue release and the “through the joint” methods are discussed.     

Necrotizing soft tissue infections

Necrotizing soft tissue infections (NSTI) represent a spectrum of diseases characterized by extensive rapidly progressive necrosis that may involve the skin, subcutaneous tissues, fascia or muscle. Their progress is extremely fast, leading often to sepsis and septic shock that ends up in multiple organ failure with abrupt and high mortality. A variety of classification systems have been developed based on parameters such as anatomic location of the disease or microbiology. There are a number of factors that predispose to the spread of these soft tissue infections, such as delays in recognition, immune suppression, diabetes mellitus and advanced age. The use of broad‐spectrum antibiotics tends to mask the severity of the underlying infection, modulates the clinical presentation, and even delays hospital admission. The most important factor affecting outcome in NSTI is early diagnosis and aggressive radical surgical treatment. The medical records of 13 patients who had been treated for NSTI from 1996 to 2005 were reviewed, retrospectively. There were eight men (61.5%) and five (38.5%) women. Mean age was 56 years (range 27–73). Seven cases of infection involved the perineal region (54%), two the lower limb, one the upper limb and three the abdominal wall/trunk. The most common associated comorbidity was diabetes mellitus in five patients (38.5%). A single organism was identified in two (15%) and multiple organisms in 11 (85%) patients. Necrotizing aponeurositis Type I was the most common of the polymicrobial necrotizing infections. Overall survival was 85%, and the mean hospital stay for survivors was 35 days (range 17–92).     

Perineal soft tissue infections

Fournier's gangrene (FG) is an aggressive necrotizing soft tissue infection of the perineum. FG takes hold as a mixture of pathogenic organisms enter the host via injured gastrointestinal or genitourinary mucosa. After soft tissue insult, a synergistic, polymicrobial infection destroys tissue through an obliterative endarteritis. FG particularly affects older, obese men with type 2 diabetes mellitus, but can affect everyone. Special populations at risk include patients who have undergone gender reassignment surgery. Early, aggressive debridement and fluid resuscitation are mandatory. Careful decisions must be made regarding the fecal stream, antibiosis, topical coverings and the use of adjunctive therapy. While untreated FG is certainly fatal, with effective diagnosis and treatment survival rates approach 95%.     

Permanent soft tissue fillers

As our youth-oriented society ages, interest in nonsurgical aesthetic techniques has generated a dramatic rise in the use of filling agents for facial rejuvenation. Backed by multiple published studies documenting safety and efficacy, soft tissue fillers are often viewed as treatments with minimal recovery time and limited risk of complications when compared with traditional surgical interventions. This has led to a genuine demand for fillers with similar safety profiles but ever increasing longevity in their aesthetic corrections. This review addresses many of the permanent soft tissue fillers that are commercially available worldwide as well as important concerns regarding their complications.     

腹膜后软组织肉瘤

腹膜后软组织肉瘤是一种少见的恶性肿瘤,治疗的关键是彻底完整的切除肿瘤物。     

Malignant soft tissue tumors

This article is a survey of actual aspects. With regard to frequency, the malignant fibrous histocytoma comes first, followed by lipo- and fibrosarcoma, synovial sarcoma, malignant schwannoma, malignant tumours proceeding from arteries and veins and the unstriated musculature. Staging and grading of these tumours are difficult. Until now their overall TNM-classification was not possible due to insufficient hard criteria.     

Pediatric soft tissue sarcomas

Soft tissue sarcomas in children are rare. Approximately 850 to 900 children and adolescents are diagnosed each year with rhabdomyosarcoma (RMS) or a non-RMS soft tissue sarcoma (NRSTS). RMS is more common in children 14 years old and younger and NRSTS in adolescents and young adults. Infants get NRSTS, but their tumors constitute a distinctive set of histologies. Surgery is a major therapeutic modality and radiation plays a role. RMS is treated with adjuvant chemotherapy, whereas chemotherapy is reserved for the NRSTS that are high grade or unresectable. This review discusses the etiology, biology, and treatment of pediatric soft tissue sarcomas.     

Lymphoma presenting as a soft tissue mass. A soft tissue sarcoma simulator

Lymphoma presenting as a soft tissue mass is rare and thus may be confused with the more common soft tissue sarcoma. No previous analysis of the clinical and radiologic features of lymphomas presenting as soft tissue masses is available because most of the cases reviewed are from the pathology literature. Four patients with diagnoses of extranodal lymphomas of the soft tissues were reviewed retrospectively with respect to their clinical features, primary tumor characteristics, stage, radiographic characteristics, treatment, and followup. Mean age was 72.5 years (range, 52-85 years). The soft tissue mass occurred in the thigh (three cases) and shoulder (one case). The median size of the soft tissue mass was 6.7 cm (range, 2-15 cm) in the largest dimension, as measured on magnetic resonance imaging. These patients each had evidence of lymphadenopathy at the time of diagnosis. Lactate dehydrogenase was increased significantly in two cases and increased slightly in two other cases. One case was Stage II(E) at presentation, one was Stage III(E), and two were Stage IV. All were B cell immunophenotype. All patients died between 2 and 24 months after diagnosis, despite the use of Cytoxan, vincristine, adriamycin, and prednisone chemotherapy in each case. Clinical and radiographic features that favor extranodal soft tissue lymphoma over sarcoma include pain and tenderness, lymphadenopathy (particularly when confluent radiologically), ipsilateral extremity swelling, and elevated lactate dehydrogenase.     

Evaluation of the Radiance FN soft tissue filler for facial soft tissue augmentation

OBJECTIVE: To evaluate the clinical efficacy and patient satisfaction of Radiance FN (fine needle) (BioForm Inc, Franksville, Wis), a highly biocompatible, calcium hydroxylapatite-based implant, when used for facial soft tissue augmentation. METHODS: Ninety patients aged between 25 and 85 years underwent subdermal injection with Radiance FN. The primary areas treated were lips, nasolabial folds, glabellar rhytids, marionette lines, prejowl depressions, acne scars, and surgical soft tissue defects. Patients were surveyed after treatment and for up to 6 months for pain, ecchymosis, skin erythema, nodules, softness, appearance, and satisfaction. RESULTS: In terms of efficacy, at 6 months, appearance, softness, and overall patient satisfaction were rated good or excellent in 74%, 80%, and 88% of patients, respectively. Moderate or severe pain occurred with injection in 59% of patients but disappeared 2 to 5 minutes after injection. Erythema, edema, and ecchymosis were common immediately after treatment but resolved in all patients within 2 weeks. Seven patients had persistent visible mucosal lip nodules, 4 of whom required intervention. CONCLUSIONS: Radiance FN is highly effective and well tolerated when used for facial soft tissue augmentation. Additional experience with longer follow-up will help determine the most appropriate use and long-term safety for the implant.     

Experiences from tissue microarray in soft tissue sarcomas

The tissue microarray (TMA) technology was introduced in 1998 as a tissue preserving, high-throughput technique that allows studies of multiple markers in large sample sets. TMA slides can be analyzed using techniques such as immunohistochemistry and in situ hybridization and represents a powerful tool for the investigation of potential diagnostic and prognostic markers identified in DNA microarray studies. We review the TMA method, its reproducibility, advantages, limitations and future perspectives with specific focus on soft tissue sarcomas.     

Pathology of soft tissue tumours

Soft tissue tumours are a heterogeneous group of neoplasms with differentiation towards mesenchymal tissue. They may arise anywhere in the body and show similar clinical presentation. Traditional histopathological diagnosis is now complemented by molecular diagnostic techniques that have become firmly established ancillary diagnostic methods. This article provides a short overview of the aetiology and clinical features of soft tissue sarcomas with an update on how molecular genetics is influencing classification and management of these rare tumours.     

Pathology of soft tissue tumours

Soft tissue tumours are a heterogeneous group of neoplasms with differentiation towards mesenchymal tissue. They may arise anywhere in the body and show similar clinical presentation. Traditional histopathological diagnosis is now complemented by molecular diagnostic techniques that have become firmly established ancillary diagnostic methods. This article provides a short overview of the aetiology and clinical features of soft tissue sarcomas with an update on how molecular genetics is influencing classification and management of these rare tumours.     

Pseudoallescheria boydii soft tissue abscess

Pseudoallescheria boydii, a fungus often isolated from soil, commonly causes a mycetoma. Successful treatment involves resection of the infected area and appropriate antifungal chemotherapy. In vitro sensitivity of P. boydii to miconazole is usually demonstrated, but resistance to amphotericin B and 5-fluorocytosine is often observed. Limited data are available on the treatment of this infection with ketoconazole. An usual case of nontraumatic P. boydii soft tissue infection without draining sinus tracts occurred in a 50-year-old woman. Nontraumatic P. boydii soft tissue infection was diagnosed by cytologic preparation and fungal cultures of the aspirate. The patient was successfully treated with en bloc resection for four months of oral ketoconazole.     

Adult soft tissue sarcoma.

BACKGROUND: Soft tissue sarcomas (STS) are a group of anatomically and histologically diverse tumours. They account for about 1% of adult malignancies, and about 50% of patients diagnosed with sarcoma eventually die of the disease. These tumours are grouped together because of shared biological characteristics and treatment responses. METHODS: A review of the key literature on STS was undertaken, complemented by data taken from the prospectively accumulated database of 3442 patients treated for STS at Memorial Sloan-Kettering Cancer Center (MSKCC) from July 1982 to December 1997. RESULTS: Despite advances in knowledge of the molecular genetics of STS, the aetiology in most cases remains elusive. Management has been gradually refined over the last two decades. Core biopsy usually provides enough material for diagnosis. Computed tomography and magnetic resonance imaging provide a similar amount of information, which is usually adequate for surgical planning. Amputation as standard treatment for extremity lesions has been replaced by limb-sparing surgery in about 90% of patients. The role of adjuvant radiation has been further defined: it has been shown to be unnecessary for completely excised tumours less than 5 cm in diameter, but effective in decreasing local recurrence for others. Adjuvant chemotherapy has been controversial for many years. Recent meta-analysis of randomized trial results has found a small reduction in local and distant relapse, and a trend to better overall survival. Recurrent or metastatic disease should be completely excised if possible. CONCLUSIONS: Soft tissue sarcoma requires multidisciplinary care tailored to the individual patient and tumour for optimal results.     

Microtopography and soft tissue response

Implants placed in soft tissue evoke a foreign body reaction. Polymeric implants having smooth surfaces, such as silicone rubber implants, develop a nonadherent fibrogranulous tissue capsule which contracts over time and stiffens. Conventional porous implants, such as those made from textiles, usually have pores larger than 20 microns and they become infiltrated with inflammatory tissue. The in vivo cell reaction to polymeric surfaces having pores smaller than 10 microns has not been investigated systematically. In this study the histocompatibility of materials having mean pore diameters from 0.4 to 10 microns was assessed. A material available with several different defined pore sizes Versapor filter material) was tested in vivo to determine relation between pore size and qualitative tissue response. Silicone-coated samples were also tested to determine the dependence of the observed tissue response on the implant surface chemistry. Results showed nonadherent, contracting capsules around implants having pore diameters smaller than 0.5 microns. Implants with pores ranging from 1.4 to 1.9 microns evoked thin, tightly adherent fibrous capsules without inflammatory cells. Porosities of 3.3 microns and larger became infiltrated with inflammatory tissue. Results indicate that the observed tissue response is predominantly dependent on implant surface topography and that variation in implant material may have little effect. It is concluded that a defined surface topography of 1 to 2 microns appears to allow direct fibroblast attachment to the surface independent of its chemical or electrochemical nature. Attached fibroblasts then produce a minimal connective tissue response to the implant and prevent or diminish the presence of inflammatory cells at the implant/tissue interface.     

Management of soft tissue injuries

The author presents a brief discussion of the causes, extent, and prevention of primarily automobile-related soft tissue maxillofacial injuries. This is followed by a practical approach to their management. Personal preferences relative to armamentarium and techniques that have withstood the test of time are given, together with several maxims useful in the treatment of soft tissue trauma. Personal bias and philosophy born of years of experience in the treatment of such injuries are freely given.