Annals Academy of Medicine Singapore, Apr 15, 2006
Introduction: Necrotising fasciitis is a disease associated with high morbidity and mortality, an... more Introduction: Necrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs. Clinical Picture: Both presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation. Treatment: After initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation. Outcome: The first patient survived, while the second died. Conclusion: Traditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.
Journal of Reconstructive Microsurgery, Nov 3, 2010
The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 p... more The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.
Introduction: Large defects around the knee remain challenging reconstructive problems. We report... more Introduction: Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively. Methods and Materials: Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a ''propeller'' distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel. Results: Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel. Conclusion: The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.
Background Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant c... more Background Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant course and high mortality. Early recognition is difficult as the disease is often clinically indistinguishable from cellulitis and other soft-tissue infections early in its evolution. Our aim was to study the manifestations of the cutaneous signs of necrotizing fasciitis as the disease evolves. Methods This was a retrospective study on patients with necrotizing fasciitis at a single institution. Their charts were reviewed to document the daily cutaneous changes from the time of presentation (day 0) through to day 4 from presentation. Results Twenty-two patients were identified. At initial assessment (day 0), almost all patients presented with erythema, tenderness, warm skin, and swelling. Blistering occurred in 41% of patients at presentation whereas late signs such as skin crepitus, necrosis, and anesthesia were infrequently seen (0-5%). As time elapsed, more patients had blistering (77% had blisters at day 4) and eventually the late signs of necrotizing fasciitis characterized by skin crepitus, necrosis, and anesthesia (9-36%) were seen. A clinical staging system was developed based on our observations. Stage migration from early to late stage necrotizing fasciitis was evident with majority of patients in stage 1 at day 0 (59%), whereas by day 4, majority had developed into stage 3 (68%). Conclusion This study has demonstrated the continuum of cutaneous manifestations as necrotizing fasciitis evolves. This will help in the early recognition and intervention of this devastating condition.
The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus... more The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus femoris is dominantly supplied by the vascular pedicle which takes off from the same source artery that is harvested with the anterolateral thigh flap. Therefore, the blood supply of the rectus femoris may potentially be compromised when harvesting the anterolateral thigh flap. This study revisits the blood supply of the rectus femoris in the light of recent advances in the understanding of the vascular anatomy of the anterolateral thigh. From January 2010 to June 2011, a prospective intraoperative observational study was performed in 50 consecutive anterolateral thigh flaps, noting the dimensions and locations of (1) the descending branch, (2) the presence of the oblique branch of the lateral circumflex femoral artery, and (3) the number and size of the muscle branches supplying the rectus femoris. Temporary selective occlusion with microvascular clamps was performed to evaluate the dominance of the blood supply to the muscle. Flap harvest was then completed as planned. The oblique branch was noted to be present in 23 (46%) of 50 patients. Of these, 21 (91%) of 23 of oblique branches supplied a large muscle branch to the rectus femoris. When the descending branch alone was present, occluding the dominant pedicle will usually compromise the blood supply to the muscle. In situations where 2 large muscle branches arise from the descending and oblique branches, occlusion of either pedicle did not affect the circulation of the rectus femoris, demonstrating codominance in this situation. The vascularity of the rectus femoris can be classified as either a type A or B. Type A rectus femoris is the classic pattern with a single dominant pedicle from the descending branch. Type B rectus femoris is seen when an oblique branch supplies a codominant pedicle to the muscle. The implication of this anatomy is that in a type B rectus femoris, one of the 2 muscle branches can be safely ligated to increase the pedicle length when harvesting of the anterolateral thigh flap, without compromising the vascularity of the muscle.
The traditional approach to assessing the face is to consider the face in thirds (upper, middle, ... more The traditional approach to assessing the face is to consider the face in thirds (upper, middle, and lower thirds). While useful, this approach limits conceptualization, as it is not based on the function of the face. From a functional perspec tive, the face has an anterior aspect and a lateral aspect. The anterior face is highly evolved beyond the basic survival needs, specifically, for communication and facial expression. In contrast, the lateral face predominantly covers the struc tures of mastication. A vertical line descending from the lateral orbital rim is the approximate division between the anterior and lateral zones of the face. Internally, a series of facial retaining ligaments are strategically located along this line to demarcate the anterior from the lateral face (Fig. 6.1). The mimetic muscles of the face are located in the superficial fascia of the anterior face, mostly around the eyes and the mouth. This highly mobile area of the face is designed to allow fine mov...
Supplemental Digital Content is available in the text. Background: The composite face lift is bec... more Supplemental Digital Content is available in the text. Background: The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors’ technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure. Methods: Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors’ surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift. Results: Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury. Conclusion: The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Introduction: The Anteromedial thigh flap (AMT) lies adjacent to the territory of the anterolater... more Introduction: The Anteromedial thigh flap (AMT) lies adjacent to the territory of the anterolateral thigh flap (ALT) and can be used as a backup whenever the ALT is not feasible. Literature published on the AMT flap is limited and the vascular anatomy of the AMT flap is not well understood. Clarification of the vascular anatomy will be useful for safe and efficient planning and raising of the AMT flap. Method: 14 cadaveric lower limbs were injected with latex dye and dissected to study the skin perforators larger than 0.5mm in the anterolateral and anteromedial thigh. We demonstrate the application of the AMT flap in a clinical case where a combined ALT, AMT flap was used to reconstruct a tongue and floor of mouth defect post cancer resection. Results: Perforators that supplied the Rectus Femoris muscle and the overlying skin were present in all specimens and 12/14 (85.7%) specimens had Rectus Femoris branches (RFB) originating from the descending branch of the lateral circumflex iliac artery. 82.4% of AMT perforators are musculocutaneous (14/17 specimens) and they pierce the muscular fascia along a line drawn from the mid-inguinal point to the superomedial pole of the patella. The perforators congregate at the one-quarter mark and the midpoint of this line. This line is useful for the pre-operative planning of the AMT flap. Conclusion: The anatomy of the RFB, which is critical in the blood supply of the AMT flap, is constant and predictable. The location of the perforators is predictable which aids pre-operative planning.
Necrotizing fasciitis is a potentially fatal condition that can affect any part of the body. It c... more Necrotizing fasciitis is a potentially fatal condition that can affect any part of the body. It can occur after trauma, around foreign bodies in surgical wounds, or can be idiopathic. We describe a case of necrotizing fasciitis involving the breast following an initial debridement of an inflammatory lesion.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011
Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric ... more Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric patients. Compared to sacral and trochanteric ulcers, ischial sores are the most difficult to treat, with a low success rate following conservative therapy and a high recurrence rate after surgical treatment. We report the use of the pedicled anterolateral thigh (pALT) flap for reconstruction of a chronic ischial sore. The free ALT flap has an established role in reconstruction in the head and neck and extremities. However, there are few reports concerning its clinical applications for regional reconstruction. As a pedicled flap, it has been used in the primary reconstruction of the perineum, groin, anterior abdominal wall, thigh and ischium. We present the first reported case of a paraplegic man with a recurrent ischial sore treated successfully with an island pALT flap inset via a lateral subcutaneous approach. We discuss the indications and its role as a simple and reliable secondary reconstructive option in the treatment of recurrent ischial ulcers after first-line loco-regional surgical options have been exhausted.
Objective. Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence... more Objective. Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence has been the subject of much controversy. While rarely reported, subacute forms of necrotizing fasciitis have been documented in the literature by many authors. This paper highlights some recently reported cases in the literature that clearly shows that subacute forms of necrotizing fasciitis indeed exist and may in fact be under-reported because of the lack of awareness and a consistent diagnostic criteria. Methods. A Medline search was performed with the following keyword; necrotizing fasciitis, subacute, variant and indolent. Results. Majority of reported cases did not give sufficient information to satisfy the reviewer that these cases were indeed subacute forms of necrotizing fasciitis. We identified three cases of subacute necrotizing fasciitis that clearly are subacute cases and analysed their clinical presentation. A diagnostic criterion for defining subacute necrotizing fasciitis was proposed based on these cases and the authors' clinical experiences. Conclusion. This proposed diagnostic criterion serves to facilitate future reporting and documentation of this condition. The clinical significance and implication of this are discussed.
European Journal of Clinical Microbiology & Infectious Diseases, 2004
Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treate... more Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treated at one hospital over a 2-year period. Klebsiella necrotizing fasciitis can occur via direct inoculation, local trauma or, more commonly, hematogenous spread from other septic foci. Early, aggressive, surgical debridement and appropriate antimicrobial treatment are the cornerstones of treatment for this condition. Necrotizing fasciitis due to Klebsiella spp. is unique in that it is commonly associated with multiple septic foci. While liver abscesses and endogenous endophthalmitis are better-known associations of disseminated Klebsiella infection, necrotizing fasciitis is increasingly recognized as one of the manifestations of this syndrome. When treating Klebsiella necrotizing fasciitis, awareness of the potential for multiorgan involvement should prompt a thorough search for associated foci of infection.
Annals Academy of Medicine Singapore, Apr 15, 2006
Introduction: Necrotising fasciitis is a disease associated with high morbidity and mortality, an... more Introduction: Necrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs. Clinical Picture: Both presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation. Treatment: After initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation. Outcome: The first patient survived, while the second died. Conclusion: Traditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.
Journal of Reconstructive Microsurgery, Nov 3, 2010
The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 p... more The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.
Introduction: Large defects around the knee remain challenging reconstructive problems. We report... more Introduction: Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively. Methods and Materials: Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a ''propeller'' distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel. Results: Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel. Conclusion: The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.
Background Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant c... more Background Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant course and high mortality. Early recognition is difficult as the disease is often clinically indistinguishable from cellulitis and other soft-tissue infections early in its evolution. Our aim was to study the manifestations of the cutaneous signs of necrotizing fasciitis as the disease evolves. Methods This was a retrospective study on patients with necrotizing fasciitis at a single institution. Their charts were reviewed to document the daily cutaneous changes from the time of presentation (day 0) through to day 4 from presentation. Results Twenty-two patients were identified. At initial assessment (day 0), almost all patients presented with erythema, tenderness, warm skin, and swelling. Blistering occurred in 41% of patients at presentation whereas late signs such as skin crepitus, necrosis, and anesthesia were infrequently seen (0-5%). As time elapsed, more patients had blistering (77% had blisters at day 4) and eventually the late signs of necrotizing fasciitis characterized by skin crepitus, necrosis, and anesthesia (9-36%) were seen. A clinical staging system was developed based on our observations. Stage migration from early to late stage necrotizing fasciitis was evident with majority of patients in stage 1 at day 0 (59%), whereas by day 4, majority had developed into stage 3 (68%). Conclusion This study has demonstrated the continuum of cutaneous manifestations as necrotizing fasciitis evolves. This will help in the early recognition and intervention of this devastating condition.
The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus... more The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus femoris is dominantly supplied by the vascular pedicle which takes off from the same source artery that is harvested with the anterolateral thigh flap. Therefore, the blood supply of the rectus femoris may potentially be compromised when harvesting the anterolateral thigh flap. This study revisits the blood supply of the rectus femoris in the light of recent advances in the understanding of the vascular anatomy of the anterolateral thigh. From January 2010 to June 2011, a prospective intraoperative observational study was performed in 50 consecutive anterolateral thigh flaps, noting the dimensions and locations of (1) the descending branch, (2) the presence of the oblique branch of the lateral circumflex femoral artery, and (3) the number and size of the muscle branches supplying the rectus femoris. Temporary selective occlusion with microvascular clamps was performed to evaluate the dominance of the blood supply to the muscle. Flap harvest was then completed as planned. The oblique branch was noted to be present in 23 (46%) of 50 patients. Of these, 21 (91%) of 23 of oblique branches supplied a large muscle branch to the rectus femoris. When the descending branch alone was present, occluding the dominant pedicle will usually compromise the blood supply to the muscle. In situations where 2 large muscle branches arise from the descending and oblique branches, occlusion of either pedicle did not affect the circulation of the rectus femoris, demonstrating codominance in this situation. The vascularity of the rectus femoris can be classified as either a type A or B. Type A rectus femoris is the classic pattern with a single dominant pedicle from the descending branch. Type B rectus femoris is seen when an oblique branch supplies a codominant pedicle to the muscle. The implication of this anatomy is that in a type B rectus femoris, one of the 2 muscle branches can be safely ligated to increase the pedicle length when harvesting of the anterolateral thigh flap, without compromising the vascularity of the muscle.
The traditional approach to assessing the face is to consider the face in thirds (upper, middle, ... more The traditional approach to assessing the face is to consider the face in thirds (upper, middle, and lower thirds). While useful, this approach limits conceptualization, as it is not based on the function of the face. From a functional perspec tive, the face has an anterior aspect and a lateral aspect. The anterior face is highly evolved beyond the basic survival needs, specifically, for communication and facial expression. In contrast, the lateral face predominantly covers the struc tures of mastication. A vertical line descending from the lateral orbital rim is the approximate division between the anterior and lateral zones of the face. Internally, a series of facial retaining ligaments are strategically located along this line to demarcate the anterior from the lateral face (Fig. 6.1). The mimetic muscles of the face are located in the superficial fascia of the anterior face, mostly around the eyes and the mouth. This highly mobile area of the face is designed to allow fine mov...
Supplemental Digital Content is available in the text. Background: The composite face lift is bec... more Supplemental Digital Content is available in the text. Background: The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors’ technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure. Methods: Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors’ surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift. Results: Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury. Conclusion: The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Introduction: The Anteromedial thigh flap (AMT) lies adjacent to the territory of the anterolater... more Introduction: The Anteromedial thigh flap (AMT) lies adjacent to the territory of the anterolateral thigh flap (ALT) and can be used as a backup whenever the ALT is not feasible. Literature published on the AMT flap is limited and the vascular anatomy of the AMT flap is not well understood. Clarification of the vascular anatomy will be useful for safe and efficient planning and raising of the AMT flap. Method: 14 cadaveric lower limbs were injected with latex dye and dissected to study the skin perforators larger than 0.5mm in the anterolateral and anteromedial thigh. We demonstrate the application of the AMT flap in a clinical case where a combined ALT, AMT flap was used to reconstruct a tongue and floor of mouth defect post cancer resection. Results: Perforators that supplied the Rectus Femoris muscle and the overlying skin were present in all specimens and 12/14 (85.7%) specimens had Rectus Femoris branches (RFB) originating from the descending branch of the lateral circumflex iliac artery. 82.4% of AMT perforators are musculocutaneous (14/17 specimens) and they pierce the muscular fascia along a line drawn from the mid-inguinal point to the superomedial pole of the patella. The perforators congregate at the one-quarter mark and the midpoint of this line. This line is useful for the pre-operative planning of the AMT flap. Conclusion: The anatomy of the RFB, which is critical in the blood supply of the AMT flap, is constant and predictable. The location of the perforators is predictable which aids pre-operative planning.
Necrotizing fasciitis is a potentially fatal condition that can affect any part of the body. It c... more Necrotizing fasciitis is a potentially fatal condition that can affect any part of the body. It can occur after trauma, around foreign bodies in surgical wounds, or can be idiopathic. We describe a case of necrotizing fasciitis involving the breast following an initial debridement of an inflammatory lesion.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011
Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric ... more Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric patients. Compared to sacral and trochanteric ulcers, ischial sores are the most difficult to treat, with a low success rate following conservative therapy and a high recurrence rate after surgical treatment. We report the use of the pedicled anterolateral thigh (pALT) flap for reconstruction of a chronic ischial sore. The free ALT flap has an established role in reconstruction in the head and neck and extremities. However, there are few reports concerning its clinical applications for regional reconstruction. As a pedicled flap, it has been used in the primary reconstruction of the perineum, groin, anterior abdominal wall, thigh and ischium. We present the first reported case of a paraplegic man with a recurrent ischial sore treated successfully with an island pALT flap inset via a lateral subcutaneous approach. We discuss the indications and its role as a simple and reliable secondary reconstructive option in the treatment of recurrent ischial ulcers after first-line loco-regional surgical options have been exhausted.
Objective. Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence... more Objective. Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence has been the subject of much controversy. While rarely reported, subacute forms of necrotizing fasciitis have been documented in the literature by many authors. This paper highlights some recently reported cases in the literature that clearly shows that subacute forms of necrotizing fasciitis indeed exist and may in fact be under-reported because of the lack of awareness and a consistent diagnostic criteria. Methods. A Medline search was performed with the following keyword; necrotizing fasciitis, subacute, variant and indolent. Results. Majority of reported cases did not give sufficient information to satisfy the reviewer that these cases were indeed subacute forms of necrotizing fasciitis. We identified three cases of subacute necrotizing fasciitis that clearly are subacute cases and analysed their clinical presentation. A diagnostic criterion for defining subacute necrotizing fasciitis was proposed based on these cases and the authors' clinical experiences. Conclusion. This proposed diagnostic criterion serves to facilitate future reporting and documentation of this condition. The clinical significance and implication of this are discussed.
European Journal of Clinical Microbiology & Infectious Diseases, 2004
Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treate... more Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treated at one hospital over a 2-year period. Klebsiella necrotizing fasciitis can occur via direct inoculation, local trauma or, more commonly, hematogenous spread from other septic foci. Early, aggressive, surgical debridement and appropriate antimicrobial treatment are the cornerstones of treatment for this condition. Necrotizing fasciitis due to Klebsiella spp. is unique in that it is commonly associated with multiple septic foci. While liver abscesses and endogenous endophthalmitis are better-known associations of disseminated Klebsiella infection, necrotizing fasciitis is increasingly recognized as one of the manifestations of this syndrome. When treating Klebsiella necrotizing fasciitis, awareness of the potential for multiorgan involvement should prompt a thorough search for associated foci of infection.
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