Rare Case of a Cutaneous Fingertip Schwannoma: A Case Report and Review of Literature

Background

Soft tissue masses of the hand are common and mostly benign, including ganglion cysts, glomus tumors, lipomas, and giant cell tumors of the tendon sheath. Schwannomas are benign nerve sheath tumors but are rarely found on the distal parts of the digits. The authors present a case of a schwannoma located at the tip of the finger.

Methods

An otherwise healthy 26-year-old man presented because of a 10-year history of a slowly growing mass on the tip of his right little finger that significantly interfered with his right hand function. The patient underwent hand radiographs and surgical excision of the tumor.

Results

Pathologic evaluation determined that the mass was a schwannoma with positive immunohistochemistry for S-100 and SOX-10. The patient reported complete resolution of symptoms associated with the tumor and his satisfaction with the surgical outcome.

Conclusions

Imaging studies, such as radiographs, ultrasound, and magnetic resonance imaging, are critical in the diagnostic workup of soft tissue masses of the hand to better understand involvement of the tumor to musculature, vasculature, and other pertinent bony structures. Although quite common, schwannomas may be hard to differentiate from other soft tissue tumors, and a review of the literature demonstrates the importance of providers utilizing imaging and other diagnostics before proceeding to treatment.

Pediatric Replantation after Traumatic Amputation at the Distal Forearm: Rehabilitation Protocol and Outcomes

Major limb replantation is a formidable task, especially in the pediatric setting. While meticulous microsurgical technique is required in the operating room, the authors aim to highlight the importance of postoperative rehabilitation therapy for optimal function. We highlight the case of a 12-year-old boy who suffered complete traumatic amputation through the distal left forearm. The limb was successfully replanted with successful restoration of sensation and function with the aid of intensive postoperative occupational therapy. A multidisciplinary team is of paramount importance to maximize function of a replanted upper extremity.

Treating Wounds With an Avascular Component With a Dermal Regenerative Template

INTRODUCTION

Partially avascular wounds pose a challenge to wound care surgeons.

OBJECTIVE

The authors reviewed the literature and institutional results on the use of a dermal regenerative template (DRT) over partially avascular wounds to quantify the ability of the DRT to vascularize over these wounds.

MATERIALS AND METHODS

A review of the literature was performed using Ovid MEDLINE, Google Scholar, and Cochrane Library. Patient demographics, comorbidities, wound types, surface area of avascular tissues, and skin graft take were analyzed. A retrospective review of institutional cases was conducted.

RESULTS

A total of 32 articles met inclusion criteria. The retrospective review included 26 patients with partially avascular wounds reconstructed with the DRT. Seventeen patients experienced 100% graft take, 6 experienced partial take, and 3 suffered complete loss. The percent and absolute size of avascular surface area in the wound was significantly lower in cases of complete graft take compared with partial take and complete loss (1.9% and 2.7 cm2; 9.3% and 10.0 cm2; 18.0% and 9.3 cm2, respectively, P ⟨ .001). Chronic wound status (P ⟨ .001) was significantly associated with less graft take.

CONCLUSIONS

This literature review and retrospective study confirm the DRT is a viable option to provide vascularized coverage over wounds with avascular components. This study suggests the DRT is more reliable in wounds with less than 1.9% avascular tissues and less successful in chronic wounds.

The Impact of Metabolic Syndrome on Patients Undergoing Breast Reduction Surgery

Metabolic syndrome affects 35% of individuals in the USA and has been correlated with increased complications following certain surgical procedures. There has been an increase of 11% in breast reduction procedures from 2016 to 2017 making it the seventh most common reconstructive procedure in the USA. Previous studies have identified an increase in demand for breast reduction among obese patients with BMI ≥ 30 but have not defined the role of metabolic syndrome in surgical outcomes. The authors aim to investigate the impact of metabolic syndrome on 30-day postoperative morbidity and mortality in patients who underwent reduction mammoplasty.

An incidental finding of pleomorphic adenoma of the minor salivary glands in the skin area of the lower lip

Salivary gland tumors are uncommonly seen and account for less than 3% of the head and neck tumors. Pleomorphic adenoma is a well-described benign tumor of the salivary glands, originating from myoepithelial and intercalated duct cells. It is most commonly found in major salivary glands. We present a rare and unusual case of pleomorphic adenoma of the minor salivary glands in the lower lip. The tumor was diagnosed upon excision of 1.5 × 1.2 cm(2) well-circumscribed nodule at the junction of the lower lip and chin in a 46-year-old man. The histopathological analysis confirmed presence of an epithelial salivary gland tumor with islands of plasmacytoid cells, and duct-like structures within a variable and mixed stroma.

Management of complicated wounds of the extremities with scapular fascial free flaps

Management of complicated open wounds of the extremities represents a reconstructive challenge. The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissues for optimal restoration of its form and function. We present our experience with the use of scapular fascial free flaps in the reconstruction of complicated open wounds of the extremities. During the period 2001 to 2009, a total of 12 reconstructions utilizing scapular fascial free flaps were performed: nine for upper extremity wounds and three for lower extremity wounds. Two flaps failed: in one case due to intractable vasospasm, in the other case due to lack of adequate recipient vessels. In the ten successful cases, good functional and aesthetic outcomes were achieved. Based on our experience, we conclude that the scapular fascial free flap, although technically demanding, could be considered as the flap of choice for reconstruction of complicated open wounds of the extremities; it provides ample thin and well vascularized soft tissue coverage with restoration of function and a natural contour of the extremity.

Biobrane in the management of critical microsurgical wounds of the upper extremity

PURPOSE

Evolving soft tissue necrosis and/or edema can complicate microsurgical reconstruction by leading to open wounds with exposure of critical structures: anastamosed vessels, nerves, and tendons. Not infrequently, primary closure of these wounds is not possible. Immediate skin grafting may lead to anatomical and/or functional failure of reconstructed structures, compromising immediate or long-term functional outcomes. In addition, local tissues are often unavailable, and free tissue transfer in those settings could be ill-advised, especially for small wounds.

METHODS

All of the senior author's microsurgical cases were reviewed. Four cases of replantation and one microsurgical reconstruction, where biologic dressings were used to treat critical wounds, were identified and are presented in this study along with an algorithm for the management of these types of wounds.

RESULTS

Biologic dressings are simple, effective, and reliable tools for intermediate treatment of critical microsurgical wounds. Flap or replant viability was preserved in 100% of cases without compromising functional results.

CONCLUSIONS

Biologic dressings can be used safely to treat microsurgical wounds with exposed critical structures. This use of a biologic dressing greatly simplifies the management of these types of wounds, avoiding the need for complex surgical intervention.

Simultaneous replantation of both lower legs in a child: 23 years later

Function is the single most important determinant in the assessment of the results of extremity replantations. Accordingly, the indications for extremity replantations are based on the prediction of sustained satisfactory functional outcome. There are limited reports in the literature regarding replantations of major segments of lower extremities and, particularly, long-term results of those surgeries. However, this analysis is extremely important in refinement of indications for major limb replantations. In this article, evaluation of a patient 23 years after simultaneous replantation of both lower legs is presented.

Solutions to Challenging Digital Replantations

Replantation of amputated digits remains one of the most challenging areas in plastic and reconstructive surgery. Complicated cases of digital amputation, such as fingertip amputations, multidigital amputations, and so forth, pose an even greater challenge, requiring extraordinary solutions for successful replantation. The authors present their experience with complicated digital replantations at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School. Cases presented include fingertip replantation, replantation of a finger with impairment of arterial inflow, and two cases of multidigital amputations. In one case of multidigital amputation, heterodigital replantation was performed, and in the other case, a minute skin neurovascular free flap from a nonreplantable finger was used for the reconstruction of another injured finger. Presented cases demonstrate various tools that can be successfully used in the performance of challenging digital replantations.

Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement

Current concepts of wound healing acknowledge the essential role of wound bed preparation in achieving a wound with good healing potential. Critical to wound bed preparation is the removal of necrosis, unhealthy tissue, foreign matter, and infection. One of the accepted methods of wound bed preparation is surgery. The high-power parallel waterjet is a new surgical device, which allows the operator to remove very precisely undesirable tissue and debris with maximal preservation of viable tissue. A retrospective study was performed to evaluate the efficacy, safety, and economic impact of using this technique of surgical debridement. Forty patients who had waterjet debridements were compared with 22 patients with matched wounds who had conventional surgical debridement. The waterjet group had significantly fewer procedures (p<0.002) than the conventional group. Based on these outcomes, the use of the new device in appropriate patients is expected to lead to cost savings of approximately 1,900 dollars per patient.

Malignant Melanocytic Trichoblastoma

Trichoblastoma is an uncommon benign cutaneous neoplasm of the hair germ cell. The pigmented variety of the tumor is rare. There have only been a few case reports describing the malignant counterpart of trichoblastoma. There are no reports describing a pigmented variety of malignant trichoblastoma. We are presenting a case report of a 47-year-old patient with malignant trichoblastoma containing melanin deposits and propose to define this variety of the tumor as a separate entity: malignant melanocytic trichoblastoma.

Reconstruction of Complex Facial Defects After Radical Resection of Advanced Skin Cancers

Management of patients with extensive facial skin cancers is a challenge. We present a series of nine patients with extensive facial skin cancers and our experience with managing these patients.

Flap transfer for complications of major limb replantation

Our experience in the management of necrotizing and suppurating wound complications after major upper extremity replantation is presented. Seven patients underwent wound debridement and coverage with flaps. Of these, 6 were reconstructed with latissimus dorsi flaps and 1 with the scapular flap. In 3 of these patients, concomitant hemorrhage (2 patients) or thrombosis (1 patient) was simultaneously corrected by vein grafting. In all cases there was survival of both the flap and the replanted extremity.

Rehabilitation of patients after lower limb replantations by the bone distraction method

The length of the lower extremities was equalized by the bone distraction method in four patients after replantation of lower legs. A Volkov-Oganesian or Ilizarov distraction apparatus was applied on the replanted lower leg after corticotomy of the tibia and osteotomy of the fibula, and distraction was carried out over 6 to 11 months in small, measured doses. The lower extremities were lengthened from 4 to 8 cm. The lengths of the lower extremities were fully equalized in two patients; they were partially equalized in the other two patients. This made it possible to achieve successful rehabilitation of the patients after lower limb replantation.

Simultaneous replantation of both lower legs in a child: a long-term result

The progress of contemporary medicine and operative techniques makes it possible to successfully perform the simultaneous replantation of major segments of two extremities, especially in young patients, taking into consideration their high biologic potential. An adequate antishock management, hemotransfusion therapy in particular, at all stages of treatment is an indispensable condition of a favorable outcome of such operations. The method of lengthening the extremities using a distraction apparatus is rather promising for the improvement of functional results of replantations of major segments of the lower extremities. The use of this method makes it possible to broaden the scope of indications for such operations.

Successful replantation of the lower leg after 42-hour ischemia: case report

A case of right lower-leg replantation after 42-hr ischemia is presented. Revascularization of the other foot with circulatory decompensation after 36-hr ischemia was carried out simultaneously. The replanted lower leg survived. Following its shortening in replantation by 12 cm, right lower-leg lengthening by 8 cm was carried out 1.5 years after replantation with the aid of a distraction apparatus. The locomotor function in both lower extremities recovered.

Reconstruction of a complex defect of the hand with two distinct segments of the scapula and a scapular fascial flap transferred as a single transplant

To repair multiple defects of the metacarpal bones in combination with skin defects, a combined scapular free flap on a single vascular pedicle--the subscapular artery and the accompanying veins--can be used successfully. This flap includes two distinct bone segments of the lateral border of the scapula and a scapular fascial flap. Because of its long and mobile vascular pedicle, such a transplant can be used for one-stage reconstruction of the first and other metacarpal bones of the long fingers of the hand. The scapular fascial flap included in the transplant provides good functional and aesthetic results in combined injury of the skin of the hand.

[Plastic surgery of combined cutaneo-osseous defects of the hand]

The article analyses modern methods for the restoration of of defects in the metacarpal bones, based on microsurgical techniques. A case is described in which a new method for one-stage reconstruction of the hand in combined traumatic defect in the first and second metacarpal bones and an extensive defect in the soft tissues on the back of the hand was used. The hand was reconstructed by means of a vascularized complex autograft on a common vascular pedicle which included two separate fragments of the scapula and a fascial flap of the scapular region. With the application of the described method successful functional rehabilitation of the injured hand was achieved in a short period. A good cosmetic effect of the plastic repair was also noted.

Autotransplantation of heterodigital neurovascular free flaps for plasty of finger defects

The authors report eight microsurgical operations to repair soft tissue defects of the fingers using free neurovascular autografts taken from the lateral surfaces of digits 3 and 4. In seven cases, the transferred flaps survived, and one case resulted in necrosis of the transplant. Follow-ups were from one to 12 months. Good cosmetic and functional results were recorded including restoration of sensory discrimination. The procedure described is regarded as an alternative for repairing terminal and other soft-tissue defects of the fingers.

Replantation of the upper extremity severed at the level of the ulnar joint

Two cases of upper extremity replantation at the level of the ulnar joint are presented. In both cases, the ulnar joint and adjacent anatomic functional structures were destroyed in accidents and excised during surgery. Some functional rehabilitation of the replanted extremities was obtained. In one case, the grasp function of the hand was recovered through primary use of the muscular apparatus of the upper arm. In another patient, the function of the lost ulnar joint was restored through microsurgical autotransplantation of the vascularized first metatarsophalangeal joint of the foot.

[Plastic surgery of distal defects of the fingers using free vascularized autologous grafts]

The results of 50 operations for replacement of soft tissue defects of the fingers are analysed. Plastic repair of the defects in 6 cases was performed with free neurovascular autotransplants taken from the lateral surfaces of the middle or ring finger. In 5 cases the transplanted graft healed, in one case its necrosis occurred. The late-term results were studied in follow-up periods of 4 to 34 weeks. A good aesthetic and functional result was recorded, including restoration of discriminating sense. The suggested operation is considered an alternative method for replacement of soft tissue defects of the finger tips.

[Reconstruction of the elbow joint in a replanted upper extremity using the microsurgical autotransplantation method]

Described is the method of the elbow joint reconstruction by means of free microsurgical autotransplantation of the vascularized Ist metatarsophalangeal joint. The technique has been tested in the clinic and a good functional result was obtained in a patient who had undergone emergency resection of the elbow joint in replantation of the upper limb. The authors believe that introduction of such operations in the clinical practice would significantly broaden the range of indications to replantation of the upper limb amputated at the level of the elbow joint.

Restoration of lymph drainage after extremity replantation

A clinical analysis of 171 major extremity replantations was carried out. From one month to 2.5 years after surgery, direct lymphographic studies of replanted limbs were done in 17 patients (16 upper limbs and one lower limb). Despite a complete disruption of lymphatic drainage, replanted limbs underwent adaptive and compensatory structural changes of the lymphatic system in the post-replantation period; first, with regeneration of cutaneous vessels and then (after six to eight weeks postoperatively) with regeneration of lymphatic collecting vessels. Such changes led to improvement as early as four to six weeks postoperatively and subsequently to restoration of lymphatic drainage in the replanted limb. The rate and extent of lymphatic recovery depends largely on the surgical techniques used in replantation.

[Duration of anoxia during replantation of large segments of the extremities]

Experience in 155 replantations of large segments of the extremities is discussed. The results of treatment are analysed from the standpoint of anoxia of the separated segments of the extremities. A case of replantation of the lower extremity (shin) with 42-hour anoxia is described. It is concluded that increased risk of replantation of large segments of extremities is determined in the first place by traumatic and hemorrhagic shock and not by the so-called transplantation toxicosis.