Plastic Surgery – Surgical Case Studies
Case Study: Neurofibromatosis and Chronic Leg Ulcers
I. Concept Digestion
1. Differentiation of Ulcer Types
| Feature | Venous Ulcer | Arterial Ulcer | Lymphatic Ulcer | Malignant Ulcer |
|---|---|---|---|---|
| Location | Medial malleolus (gaiter area) | Toes, heels, pressure points | Dorsum of foot | Anywhere, esp. chronic ulcer sites |
| Appearance | Shallow, irregular, granulating | Punched out, deep, necrotic | Shallow, oozing | Raised, everted edges, necrotic base |
| Pain | Mild, relieved by elevation | Severe, worse on elevation | Mild to moderate | Painless or neuropathic pain |
| Surrounding Skin | Hemosiderin deposits, eczema | Cold, hairless, shiny | Thickened, hyperkeratotic | Indurated, pigmented, satellite nodules |
| Pulses | Present | Absent/Reduced | Normal | May be normal or reduced |
| Discharge | Serous or purulent | Minimal | Proteinaceous lymph | Bloody, foul-smelling |
| Other Signs | Varicose veins | Claudication, rest pain, gangrene | Lymphedema, peau d’orange | Regional nodes, systemic signs |
III. Clinical/Applied Simulation – Consultant Round
Consultant: "You’re reviewing a leg ulcer—defaulting to 'venous' without thinking? That’s amateur. Walk me through your reasoning. I’ll fail fluff."
You (student):
- Pain: Is it worse on walking (arterial) or relieved by elevation (venous)?
- Location: Medial ankle (venous) vs toes/heel (arterial)?
- Edges: Irregular = venous, punched out = arterial, everted = malignant.
- Discharge: Serous vs lymph-rich vs bloody/foul?
- Pulses: Check all – absent is arterial clue.
- Systemic features: Weight loss, fever? Think malignancy.
Consultant: "You missed ulcer age, prior trauma, neuropathy, and lymphadenopathy. You want to be a surgeon? Redo it in SOAP."
IV. Neurofibromatosis
Definition:
- NF1 (von Recklinghausen) – Chromosome 17 – Neurofibromin mutation.
- NF2 – Chromosome 22 – Merlin mutation.
Clinical Features of NF1:
| System | Manifestation |
|---|---|
| Skin | Café-au-lait spots (≥6), axillary freckling |
| Neuro | Seizures, learning disabilities |
| Eye | Lisch nodules (iris hamartomas) |
| Tumors | Neurofibromas (cutaneous/plexiform), gliomas |
| MSK | Scoliosis, pseudoarthrosis, bone dysplasia |
| Endocrine | Pheochromocytoma, HTN |
V. Clerking Template – Neurofibromatosis + Leg Ulcer
Identification:
- Name, Age, Sex, Occupation
- Presenting complaint
HPI:
- Duration of bumps/ulcers
- Pain, discharge, prior similar issues
- Neurological Sx: vision, seizures, learning
- Ulcer: type, progression, treatment history
PMH:
- Seizures, tumors, HTN, previous surgeries
Family History:
- Neurofibromatosis features in relatives
Social:
- Stigma, occupation, education
ROS:
- CNS: headache, weakness, seizures
- CVS: palpitations, BP history
- MSK: limb deformities, scoliosis
Exam:
- Skin: Café-au-lait, freckling, neurofibromas
- Eyes: Lisch nodules
- Neuro: Focal deficits
- MSK: Pseudoarthrosis, scoliosis
- Ulcer: Type, base, edges, discharge, pulses
VI. Monitoring Skin Flap Viability
| Parameter | Interpretation |
|---|---|
| Color | Pink = good, Pale = ischemia, Blue = congestion |
| Cap Refill | Normal <2s, delayed = ischemia |
| Temperature | Cool = ischemic, compare with adjacent skin |
| Bleeding Edge | Presence = good perfusion |
| Area of Discoloration | Progression = poor perfusion |
VII. Why Not Graft Over Medial Malleolus?
- Grafts require granulation tissue – bone/tendon exposure = fail
- Flaps bring their own blood supply
- Better durability, contouring over pressure zones
- Higher success rates in ischemic or infected beds
VIII. Why Use Hb, Not PCV, for Surgical Planning?
| Reason | Explanation |
|---|---|
| Hb = O₂ carrying power | Direct measure of oxygen transport |
| PCV misleads | Affected by hydration status |
| Acute blood loss | PCV lags behind, Hb reflects real deficit |
| Volume status shift | PCV rises with dehydration falsely |
Consultant: "Stop quoting PCV like it’s gospel. Hb tells you if your patient will bleed out or breathe post-op. PCV is for clerks, not surgeons."
IX. Pre-Operative Investigations
| Test | Purpose |
|---|---|
| FBC | Anemia, infection, platelet status |
| U&E | Renal function, electrolytes |
| PT/INR/aPTT | Bleeding risk |
| HbA1c/RBS | Glycemic control |
| ECG | Baseline rhythm, ischemic changes |
| CXR | Pulmonary pathology, cardiomegaly |
| Crossmatch | Prepare for transfusion |
| HIV/HBV/HCV | Status, theatre risk, consent implications |
| Chest function tests | Indicated in COPD/asthma patients |
| Imaging | For ulcer depth, osteomyelitis, vascular supply |
X. From History – Ruling Out Types of Ulcers
Key Differentiating Questions
| Ulcer Type | Focused Questions |
|---|---|
| Venous | - Do your legs swell at the end of the day? |
| - Does elevating the leg relieve pain? | |
| - History of varicose veins? | |
| - Any brownish skin discoloration? | |
| Arterial | - Do you have leg pain when walking (claudication)? |
| - Is the pain worse at night or when legs are elevated? | |
| - Do your feet feel cold or numb? | |
| - Do you smoke or have diabetes/hypertension? | |
| Lymphatic | - Do you have a long-standing swelling of the limb? |
| - Any history of recurrent cellulitis? | |
| - Milky or clear discharge from the ulcer? | |
| - Travel to filariasis-endemic areas? | |
| Malignant | - Has the ulcer been present for many years? |
| - Is the base of the ulcer bleeding or foul-smelling? | |
| - Has it changed in size or appearance recently? | |
| - Any nearby hard lumps (lymph nodes)? |
XI. Simulation – The Angry Consultant
Consultant:
"Why the hell would you say 'venous' without asking about claudication? If that patient has rest pain and you slap a compression bandage on them, you’re writing the amputation request. Again—what. specific. history. question. rules out malignancy?"
Expected Student Response:
"Chronicity, foul discharge, and progressive change in size or bleeding are suspicious. Ask about lymphadenopathy, prior trauma, and systemic signs like weight loss."
Consultant:
"Better. But if you don’t examine pulses and don’t biopsy a suspicious ulcer—you deserve your malpractice suit. Next!"
XIII. Clinical Monitoring – Flap Post-Op Care
Mnemonic: "The FLAP CODE"
| Code Letter | Meaning | Explanation |
|---|---|---|
| F | Flush of Color | Pink = good, Pale = ischemia, Dusky = venous congestion |
| L | Local Temp | Compare with surrounding skin – cold = compromise |
| A | Area of Discoloration | Progressive darkening = early necrosis |
| P | Peripheral Bleeding | Prick the edge – absence of bleeding = bad perfusion |
| C | Capillary Refill | Normal <2s = viable |
| O | Odor/Discharge | Foul smell = infection = decompensation |
| D | Doppler Signal | Confirm arterial inflow |
| E | Edge Tension | Excess pressure = poor flow; flap too tight? |
Consultant Warning:
“You lose a flap, you fail the rotation. I want round-the-clock charting. No guesswork.”
XIV. Integration Summary (For Visual Notes / Flashcards)
Markdown Table: Ulcer Differentiation & Management
| Ulcer Type | Key Feature | Diagnostic Test | Key History Question | Treatment Approach |
|---|---|---|---|---|
| Venous | Gaiter zone, edema | Duplex US | Worse with standing? Varicosities? | Compression, elevation, skin care |
| Arterial | Toes, punched out | ABI, Doppler | Claudication? Worse at night? | Revascularization, avoid compression |
| Lymphatic | Dorsum, lymphedema | Lymphoscintigraphy | Chronic swelling? Travel history? | Compression, manual drainage, hygiene |
| Malignant | Everted edge, bleeding | Biopsy, Imaging | Chronic ulcer with changes? Weight loss? | Wide excision, oncology input |
OSCE-Style Flash Drills – Ulcer, NF, Flap Viability
STATION 1: Ulcer Diagnosis
Scenario:
A 60-year-old man presents with a 6-month history of a non-healing ulcer over the medial malleolus.
Q1: What is the most likely cause?
A: Venous ulcer.
Q2: What history supports this?
A: Chronicity, location (gaiter area), worse with standing, relief with leg elevation, hx of varicose veins.
Q3: What examination signs do you look for?
A: Hemosiderin staining, lipodermatosclerosis, varicose veins, edema, warm skin, granulating base.
Consultant Critique:
“If you didn’t check pulses before applying compression—you've just necrosed the leg. Always rule out arterial disease!”
STATION 2: Rule Out Arterial Ulcer
Scenario:
Same patient. You suspect arterial involvement.
Q1: What symptoms point to arterial ulcers?
A: Intermittent claudication, rest pain, cool skin, reduced/absent pulses, ulcers on pressure points like toes.
Q2: What test confirms your suspicion?
A: Ankle-Brachial Index (ABI). <0.9 suggests arterial insufficiency.
Consultant Critique:
"ABI first. Doppler next. If you don't check this before compression, you're committing iatrogenic murder."
STATION 3: Neurofibromatosis History Taking
Scenario:
A 25-year-old male presents with multiple skin swellings and pigmentation.
Q1: What system-based history must you ask?
A:
- Neuro: seizures, headaches, learning disability
- Derm: onset and change in lesions, pruritus
- Ortho: bone pain, scoliosis
- Eyes: vision issues, Lisch nodules
- FHx: family members with similar signs
Q2: What’s your provisional diagnosis?
A: Neurofibromatosis Type 1 (NF1)
Q3: What features meet NIH criteria?
A: ≥2 of:
- ≥6 café-au-lait spots
- Axillary/inguinal freckling
- ≥2 neurofibromas or 1 plexiform
- Optic glioma
- ≥2 Lisch nodules
- Osseous lesions (e.g., sphenoid dysplasia)
- First-degree relative with NF1
Consultant Critique:
"If you didn't screen for learning disabilities or optic issues, you've missed 40% of the complications. Unacceptable."
STATION 4: Skin Flap Monitoring Post-Op
Scenario:
Post-op day 1 following flap coverage of a medial malleolus wound.
Q1: What 5 things must be monitored hourly?
A:
- Color
- Temperature
- Capillary refill
- Edge bleeding
- Doppler signal
Q2: What’s an early sign of venous congestion?
A: Purple/dusky color with brisk bleeding
Q3: How would you test arterial flow?
A: Doppler signal and capillary refill <2s.
Consultant Critique:
"Monitoring is your life insurance. If you miss duskiness, necrosis is next. Flaps don’t forgive mistakes."
STATION 5: Graft vs Flap
Scenario:
You're deciding between a skin graft and a flap over the medial malleolus.
Q1: Why not a graft here?
A: Poor vascularity on bony prominence, lack of granulation tissue, exposed tendon/bone.
Q2: What advantages does a flap offer?
A: Brings its own blood supply, better for coverage of poorly vascularized tissue, more durable.
Mnemonic Recap:
Battle at Malleolus Fortress – Grafts need fertile fields; Flaps bring blood and army.
Consultant Critique:
"If you slap a graft on bone, it’s like planting seeds on rock—don’t waste the theatre time."
STATION 6: PCV vs Hb – Surgical Fitness
Scenario:
Pre-op anemia screen for a patient with a chronic ulcer needing skin coverage.
Q1: Why is Hb better than PCV?
A:
- Hb measures oxygen-carrying capacity directly
- PCV is volume-based, affected by hydration status
Q2: What’s a misleading situation where PCV fails?
A: Dehydration (false high PCV, normal Hb) or fluid overload (false low PCV).
Consultant Critique:
"Rely on PCV alone and you might cut into a hypoxic patient. Use Hb—end of discussion."
STATION 7: Pre-op Investigations – Interpretation
Scenario:
You’re screening a patient for elective flap surgery.
Investigations & Purpose:
| Investigation | Purpose |
|---|---|
| FBC | Anemia, leukocytosis (infection), platelet count |
| U&E | Electrolyte balance, renal function (anesthesia safety) |
| RBS/FBS | Diabetic control, wound healing potential |
| ECG | Cardiac fitness for anesthesia |
| Coagulation Panel | Bleeding risk (esp. important for flap survival) |
| HIV/Hep B/C | Infection risk, immunosuppression |
| Chest X-Ray | Pulmonary evaluation if age/comorbidity suggestive |
Consultant Critique:
"Surgery is controlled trauma. If you don’t evaluate the battlefield—don’t enter it."
Anki Flashcards – OSCE: Ulcers, Neurofibromatosis, Flaps
Q: What is the most likely cause of a chronic ulcer over the medial malleolus?
A: Venous ulcer.
Q: What history supports a diagnosis of venous ulcer?
A: Chronicity, gaiter area location, worsens on standing, improves with elevation, hx of varicose veins.
Q: What physical signs support venous ulcers?
A: Hemosiderin staining, lipodermatosclerosis, edema, varicosities, warm granulating ulcer base.
Q: What must you rule out before applying compression therapy in venous ulcer?
A: Arterial insufficiency (via pulse exam and ABI).
Q: What symptoms point to an arterial ulcer?
A: Claudication, rest pain, cool skin, diminished/absent pulses, ulcer on toes or pressure points.
Q: What is the most useful bedside test for arterial disease?
A: Ankle-Brachial Index (ABI); <0.9 indicates arterial insufficiency.
Q: What 7 system-based questions must you ask when evaluating a patient for Neurofibromatosis?
A:
- Seizures
- Headaches
- Vision changes
- Learning difficulty
- Skin lesion history
- Bone pain/deformity
- Family history of similar lesions
Q: What are the NIH diagnostic criteria for NF1 (name 4 out of 7)?
A:
- ≥6 café-au-lait spots
- Axillary/inguinal freckling
- ≥2 neurofibromas or 1 plexiform
- Optic glioma
- ≥2 Lisch nodules
- Osseous lesions
- 1st-degree relative with NF1
Q: What five parameters should be monitored post-operatively in a skin flap?
A:
- Color
- Capillary refill
- Temperature
- Edge bleeding
- Doppler signal
Q: What early sign indicates venous congestion in a flap?
A: Dusky/purple color with brisk bleeding on needle prick.
Q: Why is a flap preferred over a graft in wounds over the medial malleolus?
A: Grafts fail over bony prominences or tendon without paratenon. Flaps bring their own vascular supply.
Q: When is a skin graft contraindicated?
A:
- Exposed bone/tendon
- Poor vascularity
- No granulation tissue
Q: Why is Hb concentration better than PCV in surgical planning?
A: Hb directly reflects oxygen-carrying capacity; PCV is volume-dependent and can be misleading.
Q: In what situations is PCV unreliable?
A:
- Dehydration (falsely high PCV)
- Overhydration (falsely low PCV)
Q: List 7 essential pre-operative investigations and their purposes.
A:
- FBC: anemia, infection, platelets
- U&E: electrolyte balance, kidney function
- RBS: diabetes control
- ECG: cardiac fitness
- Coagulation screen: bleeding risk
- HIV/HepB/C: infection risk
- CXR: pulmonary baseline if indicated