NEUROFIBROMATOSIS Type NF1 – Diagnosis and Combo (CO2/Nd:YAG) Laser Therapy of NF1
DIAGNOSIS and DIAGNOSTICS OF NEUROFIBROMATOSIS NF1
Working diagnosis of NF1
Working diagnosis Neurofibromatosis type NF1 is based on history and clinical picture
– Numerous phacomatoses:
– Cutaneous and subcutaneous NF1 tumors
– Numerous stains of white coffee (cafe-au-lait),
– Impaired Vision, etc.
What are neurofibromas?
Neurofibromas are tumors of Schwann cells, fibroblasts and other glial cells (these are auxiliary or supporting cells of the nervous system).
What Type of Neurofibroma NF1 exist?
Neurofibromas can be cutaneous (subcutaneous), subcutaneous (subcutaneous), and plexiform.
Cutaneous neurofibromas are hemispherical in shape and are located just below the surface of the skin. They have soft consistencies and light brown colors. They occur in large numbers and sometimes the entire surface of the skin can be covered with groups of such tumors.
Subcutaneous Neurofibromas are solid in composition and lie deeper in the skin.
Plexiform (Large) Neurofibromas. Due to their size and soft composition, large neurofibroma (plexiform) are not hemispherical but bag-shaped and hang from the skin surface. Plexiform neurofibromas infiltrate the surrounding nerves (and large nerves are affected) and blood vessels. They look like thick plate formations, as a result of which various parts of the body (eg extremities) have thickened and deformed.
Diagnosis
Diagnosis is performed based on:
- Objective clinical examination
- Radiography
- CT (computed tomography),
- NMR (nuclear magnetic resonance)
- Biopsy and pathophysiological findings
Necessary interdisciplinary diagnostics of head, neck and body
– CT scan (computed tomography)
– targeted (MSCT) Multi Slice CT
– NMR of the skull and other parts of the body enable the visualization of tumor changes.
– An X-ray of the long bones can show their curvature and thinning of the cortex.
– Gallium scintigraphy has been increasingly used for the purpose of screening for neurofibromatosis when there is a genetic burden for its occurrence.
– Specialist pathologist’s finding required (histopathological finding)
A biopsy of skin changes with a histopathological finding shows specific histological changes and confirms the diagnosis.
– Necessary genetic testing (there is a genetic burden for its occurrence)
– Ophthalmologist’s specialist finding required
– Clinical Diagnostics Clinical diagnosis (Dermatology Specialist, Plastic Surgery Specialist)
– Extensive Radiological and Histopathological Diagnostics
It is pointless to do such extensive diagnostics in small hospitals, without interdisciplinary interaction.
In addition, it is financially and psychologically exhausting. For diagnostics the existing health insurance system is necessary.
The Instruction of your selected general medicine doctor and written instructions for specialists in Radiology, Neurology, Histopathology and Ophthalmology in University Hospital Clinic System is necessary.
Final Clinical Examination, Consultation and Treatment with NF1 Laser therapy can be done in the Private Laser, Plastic and Reconstructive Surgery Clinic.
NEUROFIBROMATOSIS NF1 LASER THERAPY
– Radical laser removal of NF1 tumors.
– Whole body therapy is performed through several sessions during which the combo laser technique is applied to radically eliminate any neurofibroma.
– Success is guaranteed by the total and radical removal of the present tumors.
– Radically removed tumors reduce the possibility of new ones appearing.
Number of neurofibromas that can be removed in one session.
– After more than 25 years of experience, the technique of treating NF 1 with laser surgery has developed so much that it allows us to remove up to 12,000 neurofibromas in one session. The average number of tumors removed during one session is about 800 neurofibromas.
– Bloodless and painless Laser surgery.
– NF 1 combo laser therapy is mostly a bleeding-free surgery. It is very rarely necessary to seal blood vessels.
– No or very little postoperative pain.
– The possibility of a laser is to totally eliminate or reduce postoperative pain. Nerve terminals and receptors are isolated by the energy of the laser beam.
– Hospital stay! Three to five days.
– Postoperative therapy in the treatment of postoperative wounds.
– In the first postoperative day, we start healing the wounds.
– Bio stimulation by use of soft laser following laser surgery promotes better healing.
– Secondary treatment of larger or smaller wounds lasts for the next 2-3 weeks.
-Appropriate wound healing, as well as keeping the wound clean, is very important not only for wound healing but also for reducing the possibility of scarring.
-Keloids and scars?
– We did not observe keloids, but hypertrophic scars usually disappear in the first 3-4 months, they disappear very quickly and leave a thin, wrinkled extremely variable surface.
-After NF 1 laser surgery, the skin surface becomes very soft and smooth; the formation of scars on the surface is not noticed.
– Recurrence and regrowth on the place NF1 tumors has been removed?
– Where the neurofibroma has been laser removed, there is no recurrence of the neurofibroma in the same place during the observation period. Control examinations are focused on whether new neurofibromas have formed in the places where the scars are.
Combo laser partially treated NF1 of chest and abdomen before and after healing
NEUROFIBROMATOSIS NF1 COMBO LASER TREATMENT
Until recently, the usual and widespread assessment of laser wounds in terms of burns of greater or lesser extent morphologically or clinically cannot be accepted as adequate.
With the application of lasers on small areas of the skin in terms of removing efflorescence’s of minimal dimensions, it was not possible to verify the differences between laser wounds and burns. Comparing multiple laser skin wounds resulting from neurofibroma removal in NF1 using CO2 Laser (10600nm), Nd: YAG (1060nm) Laser and a combined CO2 / Nd: YAG Laser Beam on large areas of skin and burn wounds, we observed that these are fundamentally different skin lesions.
Dermal lesions caused by the conversion of monochromatic laser beam energy into thermal energy on the skin are not identical to a thermal lesion caused by a direct heat source (Combustio: open flame, hot object; Ambustio: hot liquid, steam)
Material and methods: By applying CO2 or combined CO2 and Nd: YAG Laser to 140 patients with severe NF1 neurofibromatosis (Recklinghausen’s disease), we used CO2 Laser, cw-mode (continuous wave), 25 W, 1 mm Spot. Using Combo CO2 / Nd: YAG Laser we used a mixture of 25 W CO2 Laser beam with a participation of 6- 8 W Nd: YAG cw-mode Laser component.
Depending on the operational needs, we used either a focused laser beam.
Excision or evaporation of neurofibroma. The operative surfaces were either the anterior or posterior side of the body. The correlation of the laser-treated skin surface depended directly on the concentration of neurofibromas, and thus the skin damage caused by the treatment of multiple neurofibromas.
In extremely severe neurofibromatosis, both in size and density of neurofibromas, skin damage was far more pronounced. In one laser operation, we removed between 200 and 800 neurofibromas, with the average number of removed neurofibromas ranging from 400 to 500 tumors (Figure 6).
Calculating the average number of 400 neurofibromas with a diameter of 2 to 8 mm with a depth of 3 to 6 mm (Figure 7.8), an average area of 50 mm2 per removed fibroma can be obtained (r = 4mm, h = 3mm height or cylinder depth). If the obtained average area of 50 mm2 is multiplied by n = 400, up to 20 cm2 of damaged area or 30 cm3 of lost skin mass can be reached. The edge area of the laser wound, which is a potential secretory surface, must be added to the 20 cm2 area.
Considering the area of only 20 cm2 (fibroma r = 4mm), it is concluded that 31% of the skin surface is damaged. Viewed from another aspect, it is 12.5%. This corresponds to a total damaged skin area of 160 cm2 (adapted to the Du Bois formula) (Figure 9).
The rule of nine according to Wallace helps to determine the size of the damaged skin as well as the occurrence of a life-threatening condition. In adults it means over 10-15% of the burnt area and in children 5%, (Rassner). Injuries to such areas of the skin can be expected to cause a “burn disease” with all the clinical and laboratory signs. During extensive NF1 laser therapy on large areas of the skin, we assume that our observations and figures can be rounded off so that the total body damage to laser wounds is 20% of the skin surface per treatment. Comparing the surface of laser wounds with burns caused by other thermal sources, we noticed the following essential differences:
NF1 – landscape
Clinical and morphological classification of burns is not applicable to laser wounds (CO2 / Nd: YAG).
The laser-treated skin surface (t ca. 2000 ° C) experiences Stages I, II and III in seconds. Thus, redness, boils and eschar are absent and a wound is formed in the sense of a skin defect that would be comparable to Grade IV. This lightning-fast transformation of healthy skin into a wound is typical of a laser wound and a consequence of laser vaporization of tissue.
The edges of the wound are coated with approx. 0.5 to 1mm thick necrosis / coagulation zone.
There is very little necrotic, carbonized tissue material and degradation of damaged tissue is absent or minimal.
This is also the reason that laser wounds lack intoxication due to protein denaturation and there is no extensive release of inflammatory mediators.
Due to the fact that the laser wound is sealed (welding membrane) there is no loss of fluid and consequently no loss of electrolyte or electrolyte imbalance. Thus, there is no need for infusions in terms of fluid replacement and regulation of electrolyte imbalance. There are no signs of a severe general condition in the postoperative course.
There is no occurrence of hypovolemic and pain-enhanced juice. Local signs appear after 4-6 days from the operation in terms of secretion and inflammation.
In contrast, in burn wounds, the pathophysiological mechanism promotes “intoxication” and the development of “burn disease”.
The pain
The patient has no postoperative pain because during laser treatment the receptors are evaporated and the nerve endings are sealed by coagulation. Body temperature, infection and Sepsis The postoperative course after extensive laser treatment is mostly afebrile or there is a minimal increase in temperature up to 37.5 ° C.
The laser wound is primarily sterile due to the high temperature of 1000-2000 ° C that is released on the skin by the transformation of the laser beam into heat and due to the laser surgical technique without touch (no tuch technique). So the primary infection never comes.
The laser wound can become infected in the postoperative course, which is a secondary infection, and may require antibiotic therapy.
Due to possible secondary infection, anti-tetanus prophylaxis is recommended before extensive NF1 laser surgery.
The increase in sedimentation and leukocytosis in the first and second weeks are moderate.
The burn wound is of an accidental character and, as a rule, is infected either by physical contact or there is a so-called autoinfection (domestic infection), mostly with gram-positive bacteria.
After the healing of the laser wounds, we saw enormous differences compared to the healing of burn wounds.
Laser wounds are arranged at smaller or larger intervals on the surface of the skin according to the position of the removed neurofibromas. In between are undamaged skin areas.
This explains the faster and better healing of laser wounds.
Due to the existence of healthy skin “bridges”, the elasticity, extensibility and mobility of the skin are not lost both laterally and towards the surface.
Healing of laser wounds that is not accompanied by itching creates soft scars that are initially red and later acquire a yellowish color that usually fades.
Scars and keloids
The appearance of keloids is an absolute rarity. In no case did we experience the appearance of retraction scars (Narbenstränge), skin surface deformities and contractures after joint treatment.
After the NF1 operation, the skin area affected by the laser wounds is exposed to radiation of low power laser type He-Ne (20 mW, l 633 nm) and infrared diode laser (80 mW, l 830 nm) which has a positive effect on the speed and quality of wound healing.
According to our clinical experience, wounds are drier, stay clean and heal faster. It is likely that there is some correlation and complementarity of the biostimulatory effect between the surgical CO2 / Nd: YAG laser and postoperative biostimulation with the He-Ne and Infrared laser, which in turn is lacking in burns.
Table 1: CO2 / Nd: YAG-Laser Wounds “Laser Burns”
- I, II, and III are not observed by visual assessment. degree, it is a wound in terms of a skin defect • no bleeding
- there are no changes in the general condition of the organism • no pain • Sok is absent • no fluid loss • there is no electrolyte imbalance
- slight increase in body temperature
- wounds and wound edges are sealed “welding membrane”
- The laser wound is primarily sterile, there is no primary infection
- no sepsis
- The wound healing process is fast
- no keloids
- no contractures
- hospital stay 2-3 days.
Table 2:
Burns Visual assessment of burns:
Bleeding, edema, painful skin sensitivity (I – degree) appearance of bulls, wet red goat (II a – degree) in addition to the reddish color, thin grayish-white deposits appear (II b – degree) eschare, marbled dry brown-yellow crusts, necrosis, subcutaneous vein trombosis (III – degree), Carbonification (IV – degree) –
Severe general condition of the body in people with severe burns – increased susceptibility to infection – systemic inflammatory reaction syndrome (SIRS)
– adult respiratory distress syndrome (ARDS)
– multi-organ dysfunction syndrome (MODS)
– The pain
– Infection
– Sepsis
– Inflammatory reaction
– hemodynamic changes
– activation of the coagulation system
– leukocyte migration
– macrophage migration
– Fluid loss, Electrolyte imbalance, Shock
– Scars and Keloids
– Contractures
– Long-term hospital treatment
Pictures:
Conclusion
Knowledge acquired in a laser therapy of huge areas of neurofibromas at Nerofibromatosis type 1, von Recklinghausen, allows for better understanding of the laser wound and clear morphological and clinical differences that exist in relation to burns.
This can avoid misinterpretations, wrong therapy and no excitement due to the appearance of the skin surface immediately after the treatment laser.
The comparison of the laser operatively treated skin, healed with the surface full of traces of removed neurofibroama, implies what in the Anglo-Saxon literature called “Humanization of Doctors Work”, is and remains the primary goal of Surgeon’s therapy.
This therapy introduced Dr. Katalinic from Nuremberg and he became famous around the world for his laser NF1 therapy success.
A large number of papers in international publications was published. This method was initially performed together by Dr Katalinic and Dr Ciric.
Later Dr. Ciric continued and improved at his clinic.
It is performed using a laser beam combined with Carbon Dioxide and Nd:YAG lasers that allow extremely powerful movements, which achieves radical removal of tumors.
Laser surgery was selected for the treatment of NF 1 because it is necessary to remove almost a thousand fibers.
During the past decades, the Center for Neurofibromatosis therapy has been engulfed for several hundred patients in Nuremberg and in Belgrade.
Treatment is performed under general anesthesia. Highly positive treatment results are achieved.
Patients perceive an obvious improvement in a psychological sense, which improves the quality of their life as they are free from ugly tumors that can lead to complications.
The clinic is equipped with latest technology that is applied around the world. Behind the staff of our clinic is over 41 years of international experience in medicine and surgery.
Show us your trust, call us, and we will do everything to make you happy with your new look.
More information about the treatments can be obtained: Online Contact Form – Go to the page
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Laser therapy NF1 price list*
* Depending on type, volume and number of NF1 have to be treated by Laser in one Surgery session*
The final price can be made following all diagnostic data review, clinical examination during the consultation.
* Important Note:
Prices in the price list are approximate. The final price after examination and consultation with the surgeon.
Prices are expressed in EUR, payment in dinars at the Bank Intesa sales rate on the day of payment.
