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Case Study #31
The patient is a 56 year old male who presented to an outside hospital with acute onset of epigastric discomfort. He developed severe acute pancreatitis and was explored for presumed abdominal compartment syndrome. His abdomen was left open, and he was reexplored bi-weekly for two weeks. During one of the re-explorations he had an injury to the left colon necessitating an end sigmoid colostomy. He was transferred to our institution on postoperative day 15 with a 32cm wide, open abdominal wall defect (Figure 1). He was trached, hemodynamically stable, and had an albumin of 1.6. An abdominal CT scan was performed which showed a pancreatic collection with no signs of infection and a wide abdominal wall defect. On exam the patient had a fixed noncompliant abdominal wall, and given his poor nutritional state, a split thickness skin graft was not performed. In order to achieve soft tissue coverage of the defect a combination approach of Botulinum Toxin injection and DermaClose® RC application was performed.
Case Study #30
A 16 year old woman was involved in an ATV crash in the summer of 2010. She sustained an olecranon fracture and developed necrosis of the skin over the antecubital fossa on the volar right forearm. She underwent multiple procedures for stabilization of her fractures and eventually required split thickness skin grafting of the antecubital wound. Unfortunately, she developed tethering of the skin graft to the underlying muscle. This was tender with movement of her wrist and it was also cosmetically bothersome to her. The scar from her previous surgeries extends dorsally across the forearm and into the antecubital fossa area where there is a skin graft which is approximately 8 x 8cm. With flexion and extension of her wrist, there is tethering of the skin graft to the underlying flexor muscle bellies. The benefits of external tissue expansion with the DermaClose RC device were discussed. She underwent reconstruction of the site with partial excision of the graft and placement of the DermaClose external tissue expander.
Case Study #29
The patient is a 44 year old gentleman with a history of obesity, insulin dependent diabetes mellitus, MRSA, transverse myelitis and paraplegia who has suffered with multiple sacral and lower extremity pressure ulcers. He was treated in the local wound care center with local wound care, including debridements, wound VAC and dressing changes, for nearly two years. During this time, he also underwent split thickness skin grafting to the large 15x5cm right lower extremity wound which ultimately failed. Recommendation was for optimization of the patient including improved nutrition, appropriate mattress/cushioning, evaluation and treatment of osteomyelitis, blood sugar control, and thorough wound debridement. These goals were accomplished in approximately two months.
Case Study #28
The patient is a 66 year old male who fell off a ladder while working outside his house and was brought to the emergency room on 4/13/11. He suffered the following injuries: comminuted displaced fracture of the radial head, dislocation of the radius at the elbow, fractures of the proximal to mid radius and ulna with angulation and overriding, non-displaced fracture of the distal ulna, and comminuted fracture of the distal radius with intra-articular extension. He was placed in a splint and was not brought to the operating room until the following evening (4/14/2011). He underwent the following procedures via two separate longitudinal incisions over the radius and the ulnar. At that time he was also diagnosed with asub-acute compartment syndrome.
Case Study #27
This 53 year old patient had presented three days earlier when a large basal squamous cell carcinoma of the nose was removed. At the end of that operation and again today there is no evidence grossly of persistent tumor nevertheless the carcinoma was adherent to the nasal dorsum cartilage and boney periosteum. For tumor control and aesthetic reconstructive considerations near complete excision of the skin muscle upper lateral cartilages and lower portion of the nasal bones was indicated. This was explained in detail to the patient who knew of the need for a wide excision in the anticipated forehead flap and auricular cartilage reconstruction.
Case Study #26
53 yo male was in his usual state of good health until 4-5 weeks ago when he noticed increasing buttock pain, fevers and eventual Left leg swelling and pain. A CT scan of the leg, abdomen and pelvis was obtained which notes an ischio-rectal abscess that tracks down the posterior thigh to the adductor hiatus with extensive soft tissue abscess which involves the upper posterior left thigh extends into the lower left pelvis at the level of the left ischial fossa with mixed gas and fluid consistent with abscess as described above.
Case Study #25
63 y.o. male presented on 10/2010 with Type II diabetes and a recurrent ulcer under the right first metatarsal head. All symptoms of a serious diabetic foot infection. Skin perfusion pressures were >50 mmHg, ruling out significant peripheral artery disease.
Case Study #24
60 y.o. female presented on 2/22/2010 with spontaneous bacterial peritonitis. She had a history of metastatic abdominal carcinoid. On 2/24 surgery was performed and the abdomen open due to and secondary to exploratory laparotomy with grossly infected peritoneal fluid. On April 14th following eight weeks with no wound healing we decided to place DermaClose RC continuous external tissue expander. Prior attempts to heal the wound were unsuccessful.
Case Study #23
This 38 year old male patient presented with a cramp in his lower right leg. Further analysis revealed this to be 'Deep Vein Thrombosis' (DVT) which resulted in Compartment Syndrome, necessitating a Fasciotomy of the lower right leg. The resulting wound measured, 35cm x 20cm at the widest point.
Case Study #22
This 36 yr old morbidly obese diabetic female patient originally presented with multiple incisional hernia in 2008. Hernias were treated with a succession of mesh products commencing with a non-biologic before progressing to a biologic mesh in Sept. 2009.
Case Study #21
This patient is a 54 year old male with Buerger’s disease and a non-healing ischemic ulcer to the dorsum of his left hallux for almost two years. He has a 30 pack per year smoking history and quit a year ago.
Case Study #20
On 12/07/2009 this 14 yo/s injuries were the result of getting caught in a boat propeller. He underwent an above the knee amputation of the left leg and an achilles tendon repair on the right and a rotation fasciocutaneus flap used to cover tendon due to missing overlying skin. Post-op infection required debridement of the flap distally. The infection was controlled but a large defect over tendon remained.
Case Study #18
On 9/29/08 a 31 year old male presented to the trauma bay with a gunshot wound (GSW) to the left popliteal fossa. On exam the patient was found to have no palpable pulses in the left foot, with no sensation to touch and an inability to move the foot. X-ray revealed a comminuted distal femur fracture. The patient was take to the OR where first Orthopedics rodded the fracture to stabilize it.
Case Study #17
S.B is a 47 y/o male with a past medical history significant for depression and recurrent left Achilles tendon ruptures, chronic wound to the left leg 13 months duration and depression. S.B's past surgical history was significant for three open Achilles tendon surgical procedures including primary repair of an acute rupture, delayed repair of the Achilles tendon with augmentation with an allograft and a flexor hallucis tendon transfer with left hallux interphalangeal joint arthrodesis.
Case Study #16
This 45 y.o. male presented with an abscess on the plantar aspect of the 1st metatarsal. He was admitted to the local hospital and on the same day underwent an I&D procedure. His WBC count on admission was 13,000 and he had fever of 101.4. Intra-operative findings demonstrated abscess formation within the medial compartment of the plantar left foot.
Case Study #15
This is a 48yo 430-pound diabetic male that sustained a left heel puncture wound from an unknown object while in New Orleans as a relief worker following Hurricane Katrina in August of 2005.
Case Study #14
This is a 68 y/o poorly controlled diabetic that originally presented to the office complaining of a malodorous foot that was not responding well to 6
weeks of Vaseline on a dead plantar midfoot. The patient was found to be septic and in acute renal failure. He was admitted to the hospital.
Case Study #13
Patient is a 60-year-old female with diabetes mellitus. On 12/31/07, patient underwent fifth ray amputation due to osteomyelitis on fifth metatarsal. She previously underwent a below-the-knee amputation of the left over two years ago.
Case Study #12
Patient is a 58-year-old male with diabetes mellitus who on 12/01/07 underwent partial first ray amputation that was left open. This was performed due to osteomyelitis of the first metatarsal. He was getting wet-to-dry dressing changes on daily basis along with local wound care. After extensive surgical debridement the wound measured 4.0 x 2.5 cm x 1.5 cm deep.
Case Study #11
A 42 year old African-American male presents to our clinic after stepping on a bottle cap in March 2007. The patient is a poorly controlled diabetic with serum glucose running between 250 and 350 mg/dL. His medications include oral hypoglycemics, injectible Insulin and cholesterol lower drugs.
Case Study #9
4/10/2007 – This 36 year old male presented with a recurrent nevus on the central chest previously excised in childhood. The patient was bothered by the recurrence of pigment as well as by the appearance of the scar, which had widened over time. We therefore decided to re-excise the entire lesion. The patient was placed in the supine position on the operating table. The mid chest scar with recurrent nevus was outlined and then anesthetized with 1% lidocaine with epinephrine. The area was then prepped and draped in the standard sterile fashion. Full thickness excision to subcutaneous fat was performed on the entire seat of the scar including the recurrent nevus. The defect measured 9.8 x 4.5cm. The DermaClose external tissue expander was then used to begin the complex closure.
Case Study #7
4/19/2007 – This is a 61 year old female with a history of T9 paraplegia due to a motor vehicle accident when she was 34 years old. She initially developed a stage IV sacral decubitus ulcer in November 2005. The ulcer led to Osteomyelitis requiring surgical debridement and myocutaneous flap. The patient did well for almost a year. She then developed bilateral stage IV gluteal decubitus ulcers. She again underwent surgical debridement and bilateral myocutaneous flaps. The patient was also placed on an air fluidized bed and negative pressure wound therapy (VAC) was applied to the wound. The VAC was discontinued on 03/09/07. At that the time wound measured 1.1 cm x 2.5 cm with tunnel now measuring 3.8 cm. There was wound edge contraction with a well granulating wound bed with no clinical evidence of infection.
Case Study #6
This 6 x 4 cm wound located on the posterior right calf was treated with the DermaClose® RC for only 70 minutes. This was enough time to expand the adjacent tissue, thereby enabling closure by primary intention. The procedure was performed under local anesthesia.
Case Study #5
This 55-year-old male presented with melanoma of the left calf measuring 3.4 cm. Due to its size and location we elected to use the DermaClose® RC external tissue expander. The area was prepped and 1% Lidocaine with epinephrine was infiltrated.
Following the winding of the tension controller the wound was approximately 60 to 70% closed. The DermaClose® device was left in place for approximately 45 minutes at which time the wound was approximately 75% closed. The final length after closure was 6.8 cm and the procedure was performed without any complications
Case Study #4
This 75-year-old male presented with atypical fibroxanthoma of the vertex scalp. Mohs surgery was completed leaving a final defect measuring 3.0 x 3.0 cm in size. The DermaClose® RC device was put in place. The wound was then dressed with a pressure dressing and the patient was instructed to return in the next day for evaluation. The wound was then closed. The patient tolerated the procedure well and left the operating suite without complications.
Case Study #2
This 85-year-old male presented with a large squamous cell carcinoma of the left lower arm measuring 4 x 3.5 cm. The Mohs surgery was completed leaving a final defect measuring 5.3 x 4.4 cm in size. The DermaClose® RC was applied and upon returning the following day the wound had continued to reduce in size to 1.5 x 2 cm. The Derma- Close® RC was removed and five 4-0 Vicryl deep sutures were placed. The cutaneous margin was re-approximated with a running 4-0 Prolene horizontal mattress suture and several simple interrupted 5-0 Ethilon sutures. The wound was healing nicely at eight week follow-up.