[Clinical and nursing protocol in the treatment of the decubital ulcers]. / Protocollo clinico-assistenziale nel trattamento delle ulcere da decubito.

The decubital ulcers treatment needs a complex clinical approach. The ulcer healing and the absence of recurrences are not only the result of a correct surgical operation. The purpose of this work is to identify all the clinical and nursing parameters that can provide long lasting healing. We treated 105 decubital ulcers in various body areas (sacralis, ischiatic, trochanteric and calcanear regions) and we defined a clinical protocol that starts from prevention, to the admission, till the convalescence. We obtained satisfactory results with few post-operative complications and recurrences. Our protocol is widely confirmed by various authors (the radical toilette, the use of fasciocutaneous and musculocutaneous flaps and the importance of nutrition. In particular, the use of easier flaps (cutaneous, fasciocutaneous), is preferred in the first surgical option to leave other more complex techniques (musculocutaneous flap) for the recurrences treatment. Our protocol follows the patient from the first visit till several months after dismission during convalescence. The pre-operative measures (nutritional state correction, infection care, detersion improvement) as well the post-operating ones (use of circulating fluid beds, rest in bed for at least one month) result to be mandatory for a successful outcome.

Overexpansion technique in burn scar management.

Overexpansion techniques are useful in overcoming a shortage of donor site for expansion: the aim of the authors was to verify whether this technique should be chosen instead of serial expansions for creation of wider and more malleable flaps for reconstruction. From 1993 to May 2005 we have overexpanded 59 patients with burn scars. The patients always underwent reconstruction at least 2 years after complete healing. Almost any body region capable of expansion has been overexpanded. The technique is illustrated here in the reconstruction of scalp, neck, trunk and thigh. Tissue expander original volume ranged from 450 to 800 cc: the silicon implant shape was both round and rectangular. Mean overinflation was 3.6 times beyond the stated vendor's maximum volume. The principle ratios were performed in the trunk (4.375) and in the lower extremities (4.125). The largest volume instilled in a single tissue expander was 3,500 cc. Overall expansion length was on average 172.6 days (range: 101-248). All patients were compliant with inflation once a week. The reconstructions were planned as the expansion of a transposition or an advancement flap. All patients had completion of their reconstruction with satisfactory resolution of their problem: complications occurred in three of all hyperinflated prostheses. Tissue overexpansion, if carefully planned and conducted, allows the completion of reconstruction in one-stage. Instead of serial expansions, it enhances patient compliance and reduces cost.