Massive intratumor hemorrhage in facial plexiform neurofibroma

Endovascular embolization of spontaneous massive hemorrhage of a facial plexiform neurofibroma: case report and literature review

BACKGROUND

As a subtype of neurofibromatosis, the plexiform neurofibroma is a benign, autosomally inherited disorder and predisposed to tumour formation. However, life-threatening haemorrhage into facial plexiform neurofibroma is extremely rare.

CASE INFORMATION

In the current study, we showed a facial plexiform neurofibroma case with massive haemorrhage in the cranio-maxillofacial region. An emergent selective angiography of the external carotid artery was performed to identify the offending artery, which was then selectively occluded by the combination of detachable coils and Onyx-34. Thus, the minimally invasive drainage surgery was successfully performed to evacuate the haematoma.

CONCLUSION

We believe the endovascular embolization achieved its purpose by providing an initial salvage strategy for stopping active haemorrhage in plexiform neurofibroma, allowing surgeons to perform open surgery with lower complications rate.

Catgut and its Use in Plastic Surgery

The aim of this paper is to review the origin, physical properties, advantages, and usage of catgut in plastic surgery and oral surgery.In PubMed search, the search terms ("catgut" AND ["plastic surgery" OR "facelift"]) and ("catgut" AND "oral surgery") were used, resulting in 28 and 30 papers, respectively. Of those 58 papers, 31 papers were excluded. Eight other papers were added; therefore, 35 papers were analyzed.Catgut has been used in cleft palate surgery since 1938. In 1976, it was used in a superficial wound with anti-tension taping. In the 1970s, 1980s, and 1990s, catgut was used in otoplasty, scrotoplasty, hemostasis of neurofibroma, blepharoplasty, ptosis surgery, and rhytidectomy. From the 2000s until the present day, it has been preferred in many fields of plastic surgery, including pediatric lacerations and conjunctiva sutures. In oral wound repairs and tonsillectomy, catgut has been used from the 1970s to the present. Many studies have compared catgut with other suture materials in terms of wound healing, inflammatory reaction, and longevity, and their respective advantages and disadvantages continue to be discussed.The advantages of catgut as a suture material are as follows: 1, The fundamental advantage of catgut is its absorbability. 2, Catgut has excellent tensile strength. 3, Sterility, when catgut is taken from a sealed tube, is assured. 4, Hardened, or 'chromed,' catgut is preferable to the 'plain' variety. 5, The finest possible size should be used in preference to thicker sizes.Catgut sutures are still widely used in plastic surgery and oral surgery.

Neurofibromatosis 1 French national guidelines based on an extensive literature review since 1966

Neurofibromatosis type 1 is a relatively common genetic disease, with a prevalence ranging between 1/3000 and 1/6000 people worldwide. The disease affects multiple systems with cutaneous, neurologic, and orthopedic as major manifestations which lead to significant morbidity or mortality. Indeed, NF1 patients are at an increased risk of malignancy and have a life expectancy about 10-15 years shorter than the general population. The mainstay of management of NF1 is a patient-centered longitudinal care with age-specific monitoring of clinical manifestations, aiming at the early recognition and symptomatic treatment of complications as they occur. Protocole national de diagnostic et de soins (PNDS) are mandatory French clinical practice guidelines for rare diseases required by the French national plan for rare diseases. Their purpose is to provide health care professionals with guidance regarding the optimal diagnostic and therapeutic management of patients affected with a rare disease; and thus, harmonizing their management nationwide. PNDS are usually developed through a critical literature review and a multidisciplinary expert consensus. The purpose of this article is to present the French guidelines on NF1, making them even more available to the international medical community. We further dwelled on the emerging new evidence that might have therapeutic potential or a strong impact on NF1 management in the coming feature. Given the complexity of the disease, the management of children and adults with NF1 entails the full complement healthcare providers and communication among the various specialties.

Peripheral nerve sheath tumors of the upper extremity and hand in patients with neurofibromatosis type 1: topography of tumors and evaluation of surgical treatment in 62 patients

Objective: Neurofibromatosis type 1 (NF1) is an autosomal dominant tumor predisposition syndrome with a tendency to develop peripheral nerve sheath tumors (PNST). Plexiform neurofibromas (PNF) are detected in a high proportion of affected patients. The tumors can lead to severe disfigurement and are classified as precancerous. This study examines the surgical procedures that have been performed on large PNST of the upper limb and hand, and investigates whether a specific distribution pattern of the tumors can be detected in surgically treated cases.

Methods: Surgical procedures on the upper extremity and hand performed on patients with NF1 were evaluated at an interval of 25 years (1992–2016). Topography of the tumors was classified according to dermatomes. The number of interventions per patient, duration of operations, and complications of the interventions were registered. An overview of the surgical treatment of PNST of the upper limb and hand was obtained from the literature, with special consideration of the genetic background of treated tumors.

Results: One hundred and sixty-three surgical interventions on the upper limb and hand were performed in 62 patients with NF1 for the treatment of large PNST, predominantly PNF (age: mean value: 27.33 years, male: 33, female: 29; right side: 25, left side: 26, bilateral: 7). Surgical procedures lasted an average of 72.47 minutes. In approximately half of the patients, one surgical procedure was sufficient. Duration of stay in hospital was on average 7–11 days. Neurological complications were rarely noted and occurred only temporarily. There were no dermatomes affected by PNF with particular frequency. However, some dermatomes were more often simultaneously affected by a PNF at the same time as others.

Conclusion: Although the distribution pattern shows some accumulation of tumor localization, tumors are distributed evenly and show very variable size and extent in individual cases. Surgical treatment of PNF of the upper limb and hand helps alleviate the physical discomfort that these patients have from their disfiguring disease. Repeated interventions are necessary relatively often in order to adapt the tumorous region to the outline of the limb and to improve its function.

Repair of Occipital Bone Defects in Neurofibromatosis Type 1 by Means of CAD/CAM Prefabricated Titanium Plates

Certain skeletal defects may develop in neurofibromatosis type 1 (NF1), a common tumor-suppressor syndrome, such as cranial lesions confined to the lambdoid suture region. Here, we report on the repair of osseous defects of occipital bone in a NF1 patient with history of skull trauma and tumorous hemorrhage. Computer-aided design and computer-aided manufacturing (CAD/CAM)-assisted devices were applied to safely close the bone defects. The variable phenotype of NF1 in the occipital skull region is discussed and a brief review is presented on NF1-related therapies for tumors and malformations of the occipitoparietal skull region.

Surgical management of craniofacial neurofibromatosis type 1 associated tumors

Neurofibromatosis type 1 is a rare, autosomal dominant disorder than can present with varying degrees of disfigurement depending on the associated tumor extent and location. Surgical resection is considered the most effective management of these typically benign tumors, indicated when symptoms include pain, extreme deformity, or interference with normal physical function. Giant tumors of the craniofacial region present particular difficulty due to the size of the post-resection wound deficit and the high risk surgery poses to function such as vision and facial animation in this region. Strategies of management are discussed.

Diffuse neurofibroma of scalp

A 22-year-old man presented with a large, soft, compressible swelling in the right occipito-parietal region. Fine needle aspiration cytology revealed blood only. The lesion was excised and histopathology studies revealed it to be a diffuse neurofibroma.

Spontaneous hemorrhage of a facial neurofibroma: endovascular embolization before surgical intervention

A 50-year-old man with neurofibromatosis type 1 presented to the emergency department after a spontaneous hemorrhage into a facial plexiform neurofibroma. An emergent selective angiography of the external carotid artery was performed with Onyx embolization of the origin of the internal maxillary artery as well as the superficial temporal artery to minimize arterial bleeding during the subsequent operative hematoma evacuation. This technique was aimed to control blood loss during the surgical procedure and reduce the amount of transfusion product required for resuscitation. This technique provides a viable option to control potentially life-threatening arterial bleeding in emergent settings.

Multidisciplinary management of a giant plexiform neurofibroma by double sequential preoperative embolization and surgical resection

Plexiform neurofibromas are benign tumors originating from subcutaneous or visceral peripheral nerves, which are usually associated with neurofibromatosis type 1. Giant neurofibromas are very difficult to manage surgically as they are extensively infiltrative and highly vascularized. These types of lesions require complex preoperative and postoperative management strategies. This case report describes a 22-year-old female with a giant plexiform neurofibroma of the lower back and buttock who underwent pre-operative embolization and intraoperative use of a linear cutting stapler system to assist with haemostasis during the surgical resection. Minimal blood transfusion was required and the patient made a good recovery. This case describes how a multidisciplinary management of these large and challenging lesions is technically feasible and appears to be beneficial in reducing perioperative blood loss and morbidity. Giant neurofibroma is a poorly defined term used to describe a neurofibroma that has grown to a significant but undefined size. Through a literature review, we propose that the term "giant neurofibroma" be used for referring to those neurofibromas weighing 20% or more of the patient's total corporal weight.

Free flap reconstruction of extensive defects following resection of large neurofibromatosis

BACKGROUND

Neurofibromatosis type 1 (NF-1) is a locally invasive tumor that can grow extensively with diffuse infiltration into surrounding tissue. Resecting a large neurofibroma can result in an extensive defect that is difficult to reconstruct and can cause both aesthetic and functional deformities.

METHODS

From 2000 to 2010, 5 patients with NF-1 underwent radical resection and immediate reconstruction with 6 free flaps at our institution. All patients presented with recurrent tumor, and involved head and neck region in 4 and foot in 1 patient. Ages ranged from 18 to 75 years. The follow-up ranged from 1 to 94 months.

RESULTS

Defect sizes ranged from 84 to 252 cm. A single free flap was used in 4 cases and 2 free flaps were used in 1 case. All the flaps survived. Complications included loss of skin graft, necrosis of the distal tip of a flap, and wound dehiscence. All complications were successfully managed with minor surgical procedures.

CONCLUSION

Immediate reconstruction using a free flap after resecting a large neurofibroma is a safe and reliable method that facilitates radical resection of the tumors that are difficult to resect and that may result in an extensive defect.

Intravascular embolisation and surgical resection of a giant neurofibroma with intratumoural haemorrhage

The use of pre-operative embolisation has been described for small neurofibromas, but not for giant lesions. Advances in embolisation techniques are extending the indications for this procedure, in particular to assist with operative intervention on a range of lesions. This case report describes a 45-year-old male with a giant neurofibroma who underwent embolisation to stabilise intratumoural haemorrhage and to assist with haemostasis during the subsequent surgical resection. Minimal transfusion was required and the patient has made a good recovery. This case demonstrates that pre-operative embolisation of these large and challenging lesions is technically feasible and appears to be beneficial in reducing perioperative blood loss and morbidity.

[Orbitotemporal facial involvement in type 1 neurofibromatosis (NF1)]

Plexiform neurofibromas of the orbit, sometimes extending to the temporal region and the face, are considered to be a rare but devastating and disfiguring complication of neurofibromatosis type 1. The first symptoms appear in infancy and the involvement of the orbit and the face is present in nearly all children after the age of 5. The disease is unilateral in most cases but can exceptionally involve both sides of the face. Progressive deformation of the orbital frame due to the expanding plexiform neurofibroma and buphthalmos occurs in a large proportion of cases. The associated sphenoidal dysplasia, which is thought to be, according to the most recent hypothesis, genetically determined, will inescapably increase the burden to the orbital content, cause pulsating proptosis and will endanger noble structures, finally resulting in loss of vision. Using the Jackson classification, the authors report their personal series of 22 cases (19 operated). Until now, there has been no effective medical treatment for plexiform neurofibroma and surgery remains the standard care for these patients. Controversies remain about the timing of the first operation and today most multidisciplinary teams involving plastic, maxillofacial, ophthalmologic, and neurosurgeons favor early intervention to try to minimize the secondary deformation of the orbital and facial skeleton. A number of cases of plexiform neurofibromas are illustrated within the three Jackson groups and treatment results of the rare elephantiasis neuromatosa cases are presented. Special techniques such as preoperative embolization of heavily vascularized plexiform neurofibroma are also discussed.

Giant hemifacial plexiform neurofibroma arising from trigeminal ganglion

We present a case of a massive hemifacial plexiform neurofibroma. The tumor arose from the right trigeminal ganglion in the middle cranial fossa, involving the 3 divisions of the trigeminal nerve. This affected the whole right side of the face. The principles of management are discussed.

Giant thoracic neurofibromatosis type 1 with massive intratumoral haemorrhage: a case report

A 44-year-old man known to have neurofibromatosis type 1 (NF1) presented with an acute enlargement of a long-standing pedunculated thoracic mass and a 4.5 kg weight gain. He was recently treated with anticoagulation for a newly diagnosed atrial fibrillation. Intratumoral bleed was thus suspected to explain the sudden enlargement. Chest computerised tomography confirmed the presence of a large extrathoracic tumour of soft tissue density compatible with a diagnosis of neurofibromatosis and a recent massive intratumoral haematoma. Perioperative angiography demonstrated remarkable hypervascularity. The treatment plan involved embolisation and surgical resection. The histological specimen confirmed a diagnosis of neurofibromatosis type I without malignant transformation. Neurofibromatosis associated with an intratumoral haemorrhage is rare. This is the first scientific report of a massive intratumoral bleed in NF1 subsequent to anticoagulant administration. Anticoagulation should be monitored very closely in neurofibromatosis patients due to their propensity to bleed secondary to the abnormal vascular intima.

Giant facial haematoma in neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is an inherited autosomal dominant disorder. Haematoma is an unusual complication of neurofibromatosis and extremely rare in the maxillofacial region. A case of haematoma in NF1 of the left face is presented. MR images of acute haematoma in NF1 and radiographic features of the mandible are described. Stenosis of the internal jugular vein was noted in MR angiography (MRA). Surgical resection of the tumour and evacuation of blood clots were performed. Histological and immunohistochemical examination demonstrated that the neurofibroma tumour cells infiltrated the mural layer of vessels without malignant translation. MRI is a good choice for depicting haematoma in neurofibromatosis. Intratumour haemorrhage may result from the infiltration of vessels into the lesion and minor trauma on the affected area.

Ear deformity due to neurofibromatosis type 1

Neurofibromatosis is an autosomal dominant neurogenetic disorder. It is associated with significant morbidity and results in substantial loss of function as well as significant cosmetic problems. Elephantiasis neurofibromatosa is the most impressive manifestation of the disease because of its size. In this setting, the lesion leads to massive overgrowth of both the skin and the associated soft tissue, causing disturbing deformities. The reported patient had huge plexiform neurofibromas involving both the external right ear and neck regions. Deformed external ear and neck regions were restored surgically with satisfactory cosmetic results.

Role of Maxillofacial Surgery in Patients With Neurofibromatosis Type I

Neurofibromas are a clinical manifestation of neurofibromatos is type I (NF1). Management of these tumors remains a challenge for the clinician. The goal of the present study is to point out treatment guidelines for these lesions. Eighteen patients diagnosed with NF1 and presenting lesions of the craniomaxillofacial district were included in the study. On the basis of clinical evidence and patient's expectations, only six patients of this group underwent surgery. All patients that had no surgery were included in a follow-up protocol to evaluate progression of disease. Four patients who underwent surgery had good functional/aesthetic results, whereas two patients had incomplete rehabilitation.

[Familial clinical manifestation in patients with neuromesoectodermic defect]

We relate the association of two distinct cases of neuromesoectodermosis occurred in a family, one manifested as neurofibromatosis type 1 and the other as tuberous sclerosis. The two anomalies at cousins, caused by different genetic mutations and transmitted by autosomal dominant inheritance, suggest a possible relation between them. Also, clinical manifestations are described, their consequences and the diagnostic criteria of both illnesses, emphasizing the importance of the precocious diagnosis.

Hemarthrosis: an unusual complication of type 1 neurofibromatosis

Type 1 neurofibromatosis is one of the most common autosomal-dominant disorders and often includes orthopedic manifestations. We report the case of a 48-year-old woman with hemarthrosis caused by a popliteal cyst infiltrated by a diffuse neurofibroma associated with angiodysplasia. Surgical resection of this tumor was followed by postoperative hemorrhagic complications.