The Pacman Perforator-Based V-Y Advancement Flap for Reconstruction of Pressure Sores at Different Locations.

BACKGROUND: Many procedures have been proposed for the treatment of pressure sores, and V-Y advancement flaps are widely used to repair a defect. Unfortunately, the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use.We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem, with a further modification (Pacman-like shape) to improve the covering surface area of the flap. METHODS: Between January 2012 and December 2014, the authors used 37 V-Y Pacman perforator-based flaps in 33 consecutive patients for coverage of defects located at sacral (n = 21), ischial (n = 13), trochanter (n = 1) regions. There were 27 male and 6 female patients with a mean age of 49.9 years (range, 15-74 years). RESULTS: All flaps survived completely (92.3%) except 3 in which one of them had undergone total necrosis due to hematoma and the other 2 had partial necrosis. No venous congestion was observed. The mean follow-up period was 14.9 months (range, 2-38 months). No flap surgery-related mortality or recurrence of pressure sores was noted. CONCLUSIONS: The V-Y Pacman perforator-based advancement flaps are safe and very effective for reconstruction of pressure sores at various regions. The advantage of our modification procedure include shorter operative time, lesser pedicle dissection, low donor site morbidity, good preservation of muscle, and offers remarkable excursion to the V-Y flap, which make the V-Y Pacman perforator-based flaps an excellent choice for large pressure sore coverage.

Long-term in vivo assessment of bioengineered skin substitutes: a clinical study.

The aim of the study was an objective in vivo assessment of skin properties after reconstruction with two artificial dermal substitutes, Integra® and Hyalomatrix®. Twenty-seven patients underwent reconstruction of 36 skin-loss sites with full-thickness skin graft, split-thickness skin graft, Hyalomatrix® bioengineered skin substitute and sequential split-thickness skin graft and Integra® bioengineered skin substitute and sequential split-thickness skin graft. Objective assessments were carried out using three instrumental devices: Multi Probe Adapter System MPA; 22 MHz ultrasound skin scan; and Primos Pico for a three-dimensional (3D) skin scan. The skin parameters under study in our sample were: corneometry, transepidermal water loss, elastometry, colorimetry, skin thickness and 3D skin surface pattern. A skin reconstruction with Hyalomatrix seemed to most closely approach the hydration, transepidermal water loss and skin surface 3D pattern of normal skin. A skin reconstruction with Integra seemed to demonstrate the best skin colour feature and elastic properties. Although no statistically significant differences were observed, the descriptive analysis of the outcomes might suggest a better cell regulation, regenerated extracellular matrix and neoangiogenesis with the use of Hyalomatrix, and the formation of a more elastic regenerated dermis, with overall better physical, mechanical and optical properties, with the use of Integra.

Sites of Basal cell carcinomas and head and neck congenital clefts: topographic correlation.

BACKGROUND: The embryologic fusion planes might be related with the sites of onset of basal cell carcinoma (BCC), thus supporting an embryologic role for its pathogenesis. METHODS: A study involving 495 patients with 627 BCCs of the head and neck was carried out over a period of 5 years by correlating the distribution of all BCCs with the sites of congenital clefts of the head and neck using (1) the original anatomic diagram of the Tessier classification of craniofacial clefts, (2) the anatomic diagram by Moore et al featuring the paths of the "hairline indicators" of craniofacial clefts that represent the cranial extensions of the Tessier classification, and (3) an anatomical diagram featuring the sites of congenital clefts of the neck. RESULTS: The proportion of BCCs localized within a cleft site was significantly higher than those in the noncleft sites. The age of patients with BCCs localized within the Tessier cleft number 3 was the lowest among all cleft regions. CONCLUSIONS: A topographic correspondence between the sites of BCCs and the sites of congenital clefts was demonstrated in the head and neck. This evidence would support the hypothesis of an embryologic role for the pathogenesis of BCC. The existence of clusters of embryological stem cells in the sites of fusion and/or merging of embryonic processes might therefore be proposed. There may be special biology/physiology along these cleft lines that predispose BCC formation.

Lipofilling for functional reconstruction of the sole of the foot.

BACKGROUND: New advances in regenerative surgery may increase the potential for rehabilitation in the injured foot. OBJECTIVES: A clinical prospective observational study was carried out to assess the effectiveness of lipofilling to improve the functional recovery of the injured foot. METHODS: Four patients with anatomical-functional impairment following repair of post-traumatic soft tissue loss of the foot were involved in the study. All of the patients complained of pain in the repaired plantar weight bearing area, skin instability, recurrent ulcerations and were walking on crutches. A combined plastic surgery and technical orthopaedic assessment identified the plantar areas requiring anatomical changes for load redistribution. Two selective sequential lipofillings with a 12 weeks' time interval were performed. Manufacturing of custom-made plantar insoles and/or shoes followed each surgical procedure. RESULTS: After the treatment all of the patients progressively recovered both a better plantar load distribution and a local soft tissue stability, referred the remission of chronic pain and discontinued the use of crutches. CONCLUSION: Lipofilling proved to be an effective and versatile surgical technique for both reconstructive and regenerative purposes. The interaction between the Plastic Surgery staff and the Orthopaedic Technician outlined a successful multidisciplinary approach model for the rehabilitation of the injured foot.

Hyaluronic acid three-dimensional scaffold for surgical revision of retracting scars: a human experimental study.

An observational study was carried out at the Plastic and Reconstructive Surgery Unit of the University of Pavia - Salvatore Maugeri Research and Care Institute, Pavia, Italy, to assess the clinical and histological long-term outcomes of autologous skin grafting of fresh surgical wounds following previous repair with a hyaluronic acid three-dimensional scaffold (Hyalomatrix®). Eleven fresh wounds from surgical release of retracted scars were enrolled in this study. A stable skin-like tissue cover was observed in all of the treated wounds in an average 1 month's time; at the end of this study, after an average of 12 months' time, all of the reconstructed areas were pliable and stable, although an average retraction rate of 51·62% was showed. Histological observation and immunohistochemical analysis displayed integration of the graft within the surrounding tissues. A regenerated dermis with an extracellular matrix rich in type I collagen and elastic fibres and with reduced type III collagen rate was observed. The epidermis and dermoepidermal junction featured a normal appearance with well-structured dermal papillae, too. Although the histological features would suggest regeneration of a skin-like tissue, with a good dermis and no signs of scarring, the clinical problem of secondary contracture is still unsolved.

Study to determine whether intraoperative frozen section biopsy improves surgical treatment of non-melanoma skin cancer.

Skin cancers are the most common types of cancer and their incidence has shown an increase of ∼4 to 8% per year over the last 40 years. The majority of skin cancers (∼97%) are non-melanoma skin cancers, mainly represented by basal cell (80%) and squamous cell carcinomas (20%). The use of intra-operative frozen section remains controversial in the surgical treatment of non-melanoma skin cancer, being commonly considered an optional tool, the reliability and effectiveness of which remain questionable. A large retrospective study was conducted to examine 670 surgical excisions of non-melanoma skin cancers of the head and neck in 481 patients over a period of nine years, between May, 2002 and December, 2011, at the Plastic and Reconstructive Surgery Unit of the University of Pavia, Salvatore Maugeri Research and Care Institute, Pavia, Italy. Results demonstrated the paradoxical ineffectiveness of an intra-operative frozen section biopsy in pursuing higher rates of radical excision in non-melanoma skin cancers. Nevertheless, a more detailed analysis on the use of frozen sections focusing on the various anatomical sites of the body demonstrated a reverse trend in the eyelids and canthi, where a higher success rate (87.50 vs. 69.77%) in the surgical treatment of non-melanoma skin cancers was obtained with the use of an intra-operative frozen section biopsy. Results of the present study suggested that intra-operative frozen section biopsy be routinely used in the surgical treatment of nonmelanoma skin tumors involving the eyelids and canthi.

Allogenic platelet gel in the treatment of pressure sores: a pilot study.

Although platelet gel is considered one of the most popular tools in the treatment of chronic ulcers, current consensus on its use is not unanimous. A prospective randomised trial was carried out at the Plastic Surgery Unit of the 'Salvatore Maugeri' Foundation Hospital of Pavia (Italy). The study involved 13 patients affected by spinal cord injury with 16 pressure sores over a period of 20 months. The ulcer was considered the experimental unit of the study irrespective of the number of ulcers per patient. Each consecutive ulcer was randomised to be treated either with allogenic platelet gel or with current best practice approach to chronic wounds dressing protocol. At the end of the treatment 15 ulcers out of 16 improved clinically. No statistically significant difference was demonstrated in volume reduction between the two groups, although a statistically significant difference could be demonstrated in the onset time of granulation tissue proliferation as in the wounds treated with platelet gel the healing process was triggered earlier. Our study suggests that platelet gel is mostly effective within the first 2 weeks of treatment while a prolonged treatment does not provide any significant advantage versus the current best practice approach to chronic wounds protocols.