Tissue Necrosis: A Burden of Pentazocine Abuse in South East Nigeria

Background

Tissue necrosis from pentazocine abuse is becoming a burden in our environment. Pentazocine is an opioid of the benzomorphan class. It is commonly used for post-traumatic and postoperative pain and vaso-occlusive pain of sickle cell disease (SCD). Its prolonged use can lead to addiction and may result in severe injection site necrosis, often worsened by infection due to a lack of aseptic principles during administration. Although pentazocine is a controlled drug in our environment, it is readily available.

Objectives

To review patients with tissue necrosis from pentazocine injection, share the challenges in their management, and proffer solutions.

Materials and Methods

Clinical summaries of patients with tissue necrosis and ulcers due to pentazocine addiction were reviewed.

Results

Twenty-five patients, comprising nine females and 16 males aged 22-61 years, were recorded. Twenty had SCD, while five had other underlying conditions. The duration of abuse was 1-16 years, while the average maximum daily dose was 348.75 ± 346.04 mg. Most patients used multiple sites for injection. Lesions included abscesses, tissue necrosis with ulcers, lymphoedema, exposed necrotic bones, and osteomyelitis. Most had multidisciplinary care. The outcome of wound care was good in two. Three had major limb amputations, four died, three signed against medical advice, six were still receiving care while seven were lost to follow-up. None was completely weaned from the drug at the time of this report.

Conclusion

Rising cases of tissue necrosis from pentazocine abuse are disturbing. Treatment is frustrating. Concerted efforts at prevention should be made to stem the tide.

Pedicled Radial Forearm Flap in Reconstruction of Complex Defects in the Craniofacial Region

The radial forearm flap is a fasciocutaneous flap that has been used for reconstructing defects in the craniofacial region, either as a free flap or a pedicled flap. The pedicled radial forearm flap is a reliable option for reconstructing scalp defects. Microvascular free tissue transfer has, however, remained the preferred choice in the reconstruction of most complex scalp defects in the craniofacial region. We present the cases of a 37-year-old woman with an ulcerated malignant lesion on the forehead and a 40-year-old woman with a large malignant tumor on the scalp. Excision of both lesions, which turned out to be squamous cell carcinomas, resulted in complex defects that were reconstructed with pedicled radial forearm flaps. Both patients had satisfactory results and were counseled for radiotherapy.

Proposed grading system of unilateral cleft lip to predict surgical challenges

Background

It is a common practice to subjectively categorize cleft lip deformities into narrow and wide cleft. The proposed grading of unilateral cleft lip can serve as a predictive factor of the difficulties to be encountered during repair and the expected outcome of surgery.

Materials and Methods

This was a 5-years retrospective study of the records of 32 patients with unilateral cleft lip that presented to a single surgical unit. We grouped the patients based on the age at surgery. We calculated the alar base width ratios of the cleft to non-cleft sides, and this was used for grading. We graded the clefts using ratio of 1.00-1.50 for mild cleft, 1.51 to 2.00 for moderate cleft, 2.01-3.00 for severe cleft, and >3.00 for extensive cleft lip.

Results

The youngest child was 1 month old, while the oldest was 50 years. Majority of the patients (17) were older than 2 years at the time of surgery. Only nine babies (28.1% of the patients) were able to have their surgery done within the age of 6 months. Those that had extensive unilateral cleft lip were 10 (31.3%). However, a total of 18 (56.3% of the patients) had cleft lips that were either mild or moderate grade.

Conclusion

This grading of unilateral cleft lip helps in objective preoperative assessment of the severity and in predicting the difficulty expected during lip repair. It is also helpful in assigning clefts to trainees and in determining which patients should be referred to an experienced surgeon.

Congenital Palatal Fistula with Cleft of the Soft Palate

Congenital palatal fistula or perforation is rare, unlike the acquired form which commonly results from cleft palate repair. Congenital palatal fistulae are often associated with submucous cleft palate. Only a few of this fistulae are diagnosed shortly after birth. We present the case of a 3-year old girl with congenital palatal fistula coexisting with cleft of the soft palate that was noticed shortly after birth. The palate was repaired using Bardach's palatoplasty and the client was subsequently referred to a speech therapist.

Treatment of unilateral giant fibroadenoma by breast reduction skin incision: the inverted "T" technique

BACKGROUND

Giant fibroadenoma (GFA) has been defined as fibroadenoma greater than 5 cm in it's the widest diameter and/or weighing more than 500 g. A benign lesion, its size also raises the possibility of malignancy requiring differentiation from a malignant breast disease. When unilateral GFA presents with a severe breast asymmetry, due to its size, it is not correctable by simple enucleation alone. Postoperative asymmetry from volume and ptosis disparity results, which needs to be addressed at the primary surgery. The inverted "T" technique, which is effective in volume reduction and ptosis correction in breast hypertrophy, can be applied in the treatment of unilateral GFA.

AIM

This is a retrospective review of all GFA treated by inverted "T" method.

MATERIALS AND METHODS

A retrospective review was carried out on all patients with GFA treated by inverted "T" skin pattern method over a period of 20 years (January 1988 to December 2007). The procedures were carried out at the University of Nigeria Teaching Hospital and the National Orthopedic Hospital, Enugu. Information, which included patients' demographics, pre-operative assessment, operative findings and outcome of surgery were obtained from the case files of the patients. The degree of ptosis was recorded for each patient. Diagnosis of GFA was made after clinical evaluation and pre-operative tissue biopsy. Immediate results of treatment were based on the patients' satisfaction, visual assessment of symmetry of size of breasts, correction of ptosis and position of nipple areola complex (NAC).

RESULTS

A total of 27 patients underwent inverted "T" technique for excision of GFA in their breasts. Their average age was 17.5 years (range 12-25 years) delay in presentation ranged from 2 months to 15 months. In 16 patients (59.2%), the left breast was involved in GFA whilst the tumor occurred on the right breast in 11 (40.7%). The tumor weighed on the average 1500 g (range 655-2200 g). Average diameter of the tumor was 15 cm (range 12-20 cm). All quadrants of the breasts were involved at presentation. The inferior glandular pedicle bearing the NAC was used in all patients. The length of the pedicle ranged from 8 cm to 14 cm whilst the width ranged from 6 cm to 8 cm. Lactation was reported by three patients who went on to successfully breast feed. Complications were minimal. Most were minor wound healing problems and minor breast asymmetry. Epidermolysis in 2, hypertrophic scar in 6,minor breast asymmetry in 3 and delayed healing at the "T" junction in the inframammary fold in 4 were the common complications. All patients were satisfied with the result obtained.

CONCLUSION

In GFA with a significant breast asymmetry, excision through inverted "T" technique was successful in achieving postoperative symmetry with the opposite breast in these patients. Complications were minimal.