Successful combined approach to a severe Fournier's gangrene.

We present a case of a successful reconstruction of a severe Fournier's gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.

A novel combined surgical approach to head and neck dermatofibrosarcoma protuberans.

INTRODUCTION: The surgical management of dermatofibrosarcoma protuberans has historically been a challenge, particularly in the head and neck and other aesthetic areas. The current priority is to achieve local oncologic control and a good reconstructive outcome. Here, we present our experience using a novel combined approach with a dermal regenerative template, sub-atmospheric pressure and skin graft. MATERIALS AND METHODS: Five patients presenting at the Department of Plastic and Reconstructive Surgery of the University of Florence between January 2010 and October 2011 were included in the study following Institutional Review Board approval. All patients underwent a wide local excision of dermatofibrosarcoma protuberans affecting the head and neck. RESULTS: The combined approach using the negative-pressure device, a dermal regenerative template and skin grafting proved effective in the management of this type of sarcoma with a good aesthetic and functional outcome, particularly on the neck or the supraclavicular region. CONCLUSION: Although the present multi-step technique requires patient compliance, it results in good local oncologic control of the resection margins. It is possible to perform a wider excision in the event of positive margins without interfering with the last reconstructive outcome.

Wet and dry techniques for structural fat graft harvesting: histomorphometric and cell viability assessments of lipoaspirated samples.

BACKGROUND: Autologous fat transplantation is among the surgical procedures performed most commonly by plastic surgeons for cosmetic and/or reconstructive purposes. In the procedure, autologous fat is harvested and infiltrated during the same operation, and the success of this procedure relies on harvesting and transferring viable adipocytes. This study was designed to assess the histomorphometric characteristics and viability of the lipoaspirated cells that were harvested through different techniques. METHODS: This study enrolled 65 patients undergoing lipofilling for reconstructive purposes. Subcutaneous fat samples were collected manually through the wet and dry techniques using a two-hole Coleman blunt cannula attached to a 10-cc Luer-Lok syringe. Fat tissue preservation was assessed through conventional histomorphometry and a cell viability assessment, evaluating the mitochondrial function through the MTS CellTiter 96 Aqueous One Solution Assay (Promega Corp., Madison, Wis.). RESULTS: No differences were observed between adipocyte samples harvested with or without tumescent solution. The morphometric analysis and adipocyte viability assessment confirmed the visual findings: the mean surface area and shape (circularity index) of the adipocytes were not significantly different in the lipoaspirate collected through the different techniques. CONCLUSION: The results from the present study provide the first histologic evidence and cell viability assessment to demonstrate that there are no substantial differences in the adipose tissue specimens harvested with the wet and dry techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Head and neck polypoid melanoma.

Polypoid melanoma represents a rare clinical variant of nodular melanoma skin cancer in which the tumor is connected to the skin by a pedicle, characterized by exophytic growth, ulceration, and young age at onset (20-39 years) with a special predilection for the back and with a survival rate at 5 years ranging from 32% to 42% as compared with 57% 5-year survival for nodular subtype and 77% for the superficial subtype. We present a case of a deeply pigmented polypoid melanoma arising on the face of a 77-year-old man. We performed a literature review to clarify its surgical management and prognosis.

Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb.

The standard management of degloving injuries involves either immediate grafting with the avulsed skin or full- or split-thickness grafts at a later date. Alternative methods include pedicle and free flaps and revascularisation. The authors present an innovative technique of treating degloving injuries with cryopreserved split-thickness skin grafts harvested from degloved flap, artificial dermal replacement and vacuum-assisted closure (VAC therapy). To the authors' knowledge, this is the first reported case of such bilaminar reconstruction of a degloving injury.

Contrast-enhanced ultrasound: a filter role in AJCC stage I/II melanoma patients.

One of the most significant advances in melanoma staging is sentinel lymph node biopsy (SLNB). It is a surgical technique to detect occult nonpalpable micrometastases in regional lymph nodes. Recently, contrast-enhanced ultrasound (CEUS) was introduced as a noninvasive procedure, in spite of SLNB, for the detection of SLNs in patients with cutaneous melanoma. The main purpose of this study was to evaluate the diagnostic accuracy of CEUS in the diagnostic workup of patients with melanoma in comparison with the final histology of SLNs detected through preoperative lymphoscintigraphy. Fifteen patients with cutaneous melanoma underwent prompt excisional biopsy with narrow margins in order to avoid impairment of the melanoma lymphatic basin and were referred for SLNB according to routine indications between January and February 2009. In our study CEUS showed, albeit based on a small patient sample, a negative predictive value of 100%, that means that all negative results were confirmed by negative SLN histopathological examination; all ultrasonographically negative lymph nodes corresponded to nonmetastatic sentinel nodes.

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength.

BACKGROUND: Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS: To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS: Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION: The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

Circumferential abdominoplasty.

BACKGROUND: In Italy, 34.2% of the population has a BMI higher than 25, and another 9.8% of the population has a BMI higher than 30. In Italy, there are 4 million and 700,000 obese people. Bariatric surgery has evolved as a very effective therapy for morbid obesity. After such dramatic weight loss, patients are usually left with redundant skin and unwieldy subcutaneous tissue. The circumferential truncal excess cannot be corrected by a regular abdominoplasty alone. In this group of patients, lateral excess can actually be over accentuated by a traditional abdominoplasty. In our institution, we are used performing abdominoplasty according to Pascal-Le Louarn's surgical technique. In our cases, the adoption of this technique has been successful with a high rate of very satisfied patients, no major complications and few minor complications primarily in the smoker patients. METHODS: The charts of 41 consecutive circumferential abdominoplasty were reviewed. The preoperative markings, the surgical technique, the post-operative course, and the complications are described. RESULTS: The average operative time was 220 min. The average lipoaspirate was 1,600 cc. The mean weight loss during the surgery was 3.4 kg. There were 18 immediate complications, including 11 seromas, and 7 partial wound dehiscences. There were 26 late complications, including 8 hypertrophic scars and 18 local hypoestesia. All seromas were resolved within 3 weeks. All patients were satisfied. CONCLUSION: Circumferential abdominoplasty performed with Pascal-Le Louarn's surgical technique is an effective, appropriate, and safe method to treat patients with lipodistrophy of the trunk following massive weight loss.