The combination of hyaluronic acid and collagenase in the treatment of skin ulcers: an open, multicenter clinical study assessing safety and tolerability of Bionect Start®.

OBJECTIVE: Several clinical studies have shown that hyaluronic acid collagenase is well-tolerated and very effective in managing chronic venous ulcers. The aim of the present study is to confirm the safety and tolerability of daily application in patients suffering from cutaneous ulcers of different etiologies. The efficacy of the treatment and its impact on patients' quality of life are also assessed. PATIENTS AND METHODS: Patients with a clinical diagnosis of skin ulcer with devitalized/fibrinous/slough tissue that could delay the healing process were enrolled in the study. The hyaluronic acid/collagenase ointment was applied topically until wound closure or total debridement of non-viable tissue was achieved, however, with a limit of 30 days. Monitoring was performed weekly, either through outpatient visits or telephone surveys. Assessments included adverse events, local irritation reactions, pain at dressing changes, and wound bed status. Patients were also requested to complete a quality-of-life questionnaire. RESULTS: The study involved 96 patients with a mean age of 71 years. The patients suffered mainly from traumatic (21.9%), venous (15.6%), or pressure ulcers (12.5%); in 26% of cases, ulcers had mixed etiology. In approximately 32% of patients, the ulcer had been present for more than 6 months, and 18.1% of subjects had previously undergone surgical wound debridement. CONCLUSIONS: Daily application of hyaluronic acid-collagenase achieved the following results: i) absence of adverse events related to the use of the product; ii) significant reduction in the degree of localized irritation and pain at dressing changes; iii) significant support to wound bed preparation; iv) trend towards improvement in the quality of life and health status of the patients.

ADM-assisted prepectoral breast reconstruction and skin reduction mastectomy: Expanding the indications for subcutaneous reconstruction.

BACKGROUNDS: Recently a flood of new techniques and studies have been released for prepectoral reconstruction, following strict criteria for selection of patients undergoing skin or nipple sparing mastectomy. Nevertheless a big population of patients that would otherwise benefit from prepectoral techniques has been excluded so far. PATIENTS AND METHODS: Between January 2016 and February 2017, patients undergoing skin reducing mastectomy (SRM) were enrolled at our Institution. We selected patients with large and ptotic (grade II-III) breasts undergoing SRM, followed by a new technique, which involves placement of the implant, wrapped by acellular dermal matrix, in a prepectoral pocket under a dermal flap. Data of all the surgeries were prospectively collected and contracture grade was assessed by Baker scale. Complication rate and cancer recurrence were reported and health related quality of life (HRQOL) measurement was recorded using BREAST-Q questionnaire. At early follow-up, postoperative pain was assessed through VAS scale. RESULTS: 29 patients underwent SRM and 10 patients, meeting inclusions criteria, were enrolled, with a total of 13 operated breasts. Postoperative average pain was assessed as low as 4.1. The median follow-up was 2.6 (range 2.1-3.2) years. Post-operative complications occurred in 1 case of minimal wound dehiscence. No patient reported breast seroma or severe capsular contracture grade. Patient scored high level of satisfaction with breast, psychosocial well-being, sexual well-being, physical impact and overall satisfaction with outcome, at BREAST-Q questionnaire. CONCLUSIONS: In this study we present a modified prepectoral technique for patients undergoing SRM, reporting satisfactory outcomes. These results might support the rationale for expanding the population target of prepectoral reconstruction.

The use of dermal regeneration template (Pelnac®) in a complex upper limb trauma: the first Italian case report.

Dermal regeneration template (DRT) has been well widely implicated in the reconstruction of full-thickness injury. We present our experience and our clinical application of Pelnac® to achieve wound closure with complex acute, upper limb, full-thickness defect post-trauma. A 22-year-old boy presented a soft tissues loss of the back of the hand and forearm with tendon's involvement and exposure. The wound was treated with Pelnac®; the silicone layer was removed at postoperative day 30 and dermal regeneration template was reapplied at the level of the residual tendon exposure; a split-thickness skin graft (0.2 to 0.3 mm) was inserted. Clinically, the reconstructed areas demonstrated good granulation tissue at 14 days with a good take of the skin graft. There were no major acute graft loss, rejection or associated infections cells through downregulating TLR4 expression.

Comparison between antimicrobial-coated sutures and uncoated sutures for the prevention of surgical site infections in plastic surgery: a double blind control trial.

OBJECTIVE: Surgical site infection (SSI) produces considerable morbidity and increases health care costs. One of its causes is microbial adherence to the surgical sutures surface. A strategy to avoid microbial colonization is the use of antimicrobial-impregnated sutures. Recently absorbable sutures treated with chlorhexidine (CHX) have been developed. Our study purpose was to compare CHX-coated and uncoated suture in elective plastic surgery. PATIENTS AND METHODS: We conducted a randomized, double-blind, single-centre controlled trial of 18 patients undergoing elective bilateral mammary surgery and 18 patients undergoing skin lesions removals. Patients were divided into 2 groups receiving antibacterial-coated (study group) and uncoated (controlled group) sutures for wound closure. Patients were evaluated for scar results and signs of SSIs were monitored over a period of 30 days (or 1 year in case of prosthetic surgery). Statistical comparison was performed using dependent t-tests for paired samples. RESULTS: For patients undergoing mammary surgery, based on Vancouver Scale, there were no significant differences between the two groups. We noticed that in 8 patients the vertical scars belonging to the control group were larger than the contralateral 8 vertical sutures belonging to the study group. For patients undergoing skin surgery, surgical wounds treated with uncoated sutures were significantly more erythematous than the ones belonging to the study group (Media: 0,8333% vs. 1,5556%, respectively; standard deviation: 9,235 vs. 0,6157; 95%; p=0.0092). CONCLUSIONS: No wounds infection was reported between the two groups. Based on our experience, we conclude that the use of CHX-coated sutures should be considered in case of inflamed lesions removal. Further studies are needed to validate our results.

Effectiveness of antimicrobial-coated sutures for the prevention of surgical site infection: a review of the literature.

OBJECTIVE: Surgical site infections (SSIs) are the third most common hospital-acquired infections and account for 14% to 16% of all such infections, and suture material may play a role in SSI rate. Given this risk of infection, sutures with antimicrobial activity have been developed. Both in vitro and in vivo experiments have shown that triclosan-coated sutures (TCS) are effective in the prevention of SSIs. Our aim is to analyze currently available RCTs, comparing the effect of antimicrobial-coated suture (ACS) with uncoated suture on the occurrence of SSIs following surgical procedures, we highlighted major contributions of most significant studies and evaluate the current "state of the art" on antimicrobial-coated sutures. MATERIALS AND METHODS: We reviewed 15 RCTs comparing antimicrobial-coated sutures with conventional sutures and assessing the clinical effectiveness of antimicrobial sutures to decrease the risk for SSIs. We focused our attention on each variable in all the analyzed study. RESULTS: Our selected RCTs, produced controversial results: 7 RCTs demonstrated a significant benefit, on the contrary, 8 RCTs presented a comparison in which there was no difference. CONCLUSIONS: On the basis of our selected trial results and the heterogeneous findings of our 7 selected meta-analyses, we conclude that even though the question of whether TCSs could reduce the occurrence of SSI remains still open, the antimicrobial suture was effective in decreasing the risk for postoperative SSIs in a broad population of patients undergoing surgery. Alternative substances are becoming clinically relevant, such as Chlorhexidine (CHX) coated sutures and only 6 in vivo scientific studies evaluated them. In vivo studies, large and comparative clinical research trials are necessary to validate the efficacy of CHX-coated sutures thus allowing their use in clinical practice.

Axillary ectopic lobular carcinoma of breast: two rare case reports.

OBJECTIVE: The presence of ectopic or supernumerary breast tissue is a rare event, related to a not complete regression of breast tissue along the milk line. Primary ectopic breast cancer of the axilla can create many difficulties in differential diagnosis with subsequent delayed specific treatments. The incidence of ectopic breast tissue is 0.2-6%, and the axilla is the most common site involved. In this tissue, the same physiologic and pathologic changes as seen in ectopic breast tissue may occur, including carcinoma formation. PATIENTS AND METHODS: Two patients (a 56 years old and 70 years old women) came to our attention for the recent development painless nodular axillary lesions, clinically characterized by an increased thickness, irregular margins and adherence to the floors below. RESULTS: Patients underwent ultrasonography (US) and mammography (MMG) revealing non-specific features of the lesions. Magnetic resonance imaging (MRI), demonstrated margins slightly irregular and a non-specific appearance of each lesion. Both patients underwent wide local excision with axillary lymph node dissection. Histological examination showed infiltrating lobular carcinomas of the breasts. CONCLUSIONS: We describe two unusual cases of ectopic axillary breast carcinoma localization. It is important a correct and fast diagnosis with a local examination, diagnostic instruments, surgical excision and histological examination.

Surgical therapy of breast hypertrophy: a comparison of complications and satisfaction rate in large and small superior pedicle custom-made reduction mammaplasty.

OBJECTIVE: The reduction mammaplasty is indicated for patients with symptomatic breast hypertrophy. Although surgery is considered the gold standard treatment, it is still debated which is the complication rate and whether or not there is an increased complication rate with increased tissue resection per breast. The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (≥2000 g per breast) as compared with smaller reductions (≤1999 g per breast) using the superior pedicle custom-made technique. PATIENTS AND METHODS: A retrospective study of 90 consecutive operated patients was performed. All the patients underwent a bilateral breast reduction for macromastia. 43 patients had a reduction of 1999 g or less and 47 patients had a reduction of 2000 g or more. RESULTS: There were no statistically significant differences in the rates of nipple necrosis, hematoma, seroma, wound dehiscence, wound infection, loss or reduction of nipple sensation, and a pathologic scar between the large and small resections. CONCLUSIONS: The large reduction patients pointed higher mean satisfaction rate than the small reduction patients. The superior pedicle custom-made technique is a safe method of breast reduction regardless of the degree of parenchymal resection, achieving a successful aesthetic outcome with minimal scarring and high satisfaction rate for both small and large breast reduction.

Patient satisfaction as an excellent track record in nonsurgical rejuvenation procedures.

OBJECTIVE: Patient satisfaction is the goal of most aesthetic procedures. The aim of this study is to analyse nonsurgical rejuvenation procedures in a private practice setting, over a period of 10 years, evaluating patients' compliance, satisfaction and maintenance of a good fiduciary link with the medical operator. PATIENTS AND METHODS: A retrospective study was performed on 429 patients who received nonsurgical rejuvenation procedures. Four types of treatments were considered: Botulinum toxin type A injections, Hyaluronic acid or Poly-L-lactic acid injections, and a combination therapy. The outcome analyzed included a number of patients for each treatment for each year, the treatment time interval, the number of treatments for each patient, the number of treatments according to facial sub site and the "degree of satisfaction". RESULTS: The most required treatment was combination therapy (36.8% of patients). The mean time and the median time of permanency in the study were respectively 19 and 6 months. After 18 months, which is the time that we considered to attest a good "degree of satisfaction", 55% of patients were still in the study. Patients with only one treatment were excluded. CONCLUSIONS: The study findings support evidence of a more recently described increase in popularity in minimally invasive aesthetic procedures, of which combination therapy has the best performances with a good degree of satisfaction.

Upper lip reconstruction and aesthetic aspects in the female patient: our point of view.

Brief title: A brief description of our point of view about upper lip reconstruction supporting a quite simple and effective surgical option, which surgeons could consider whenever little neoformations must be removed from the lips, an aesthetically important anatomical region.

Breast reduction: personal technique.

INTRODUCTION: Macromastia is a health problem that requires the coordination of surgical and medical specialists. Goals of reduction mammaplasty are to alleviate physical, emotional and psychosocial discomforts and to restore a conical-shaped breast, maintaining scars as short as possible. We report our approach for reduction mammaplasty with superior pedicle. MATERIALS AND METHODS: Our method combines advantages of round block with vertical scar, using a dermal flap that is fixed to the new mammary crease. We analyzed skin and glandular resection customizing the mammaplasty. RESULTS: The dermal flap works against the weight of residual tissue, maintaining the crease at the desired position with a natural result. Benefits are an excellent projection, short scar, suitable reshaping and patient satisfaction. CONCLUSIONS: This technique can be used for mild to severe hypertrophy with various degrees of ptosis. It results in a successful aesthetic outcome with minimal scarring, suitable breast remodeling and natural long-lasting projection.

Bilateral hand squamous-cells carcinoma in patient affected with non-Hodgkin lymphoma. Case report and literature review.

BACKGROUND: Squamous-cell skin cancer is the most frequent tumor in the hand. It occurs on sun-damaged skin, especially in lightskinned individuals with a long history of chronic sun exposure. CASE REPORT: We describe a case of bilateral hand squamous-cell carcinoma in a elderly patient affected with non-Hodgkin's lymphoma, who underwent several non-successful surgical treatment, radiotherapy and at the least, amputation of right hand for rapid clinical evolution after radiotreatment. Available literature on the subject has been reviewed. RESULTS: In our case, after several non-successful treatment, elective amputation at the distal third of forearm was performed. We reviewed 56 items including books, original articles, reviews, cases report. CONCLUSIONS: Current evidence on treatment of hand squamouscells carcinoma is to perform a first radical surgical treatment in order to avoid recurrence/metastasis and to achieve a safer level of amputation thus increasing the surface area of healthy tissue available for eventually subsequent reconstruction/prosthesization.

Iginio Tansini revisited.

The origin of the muscolocutaneous latissimus dorsi flap dates back to 1906 when Igino Tansini, an Italian surgeon, described a procedure to reconstruct the mastectomy defect. After a detailed study of Tansini's original description and drawings, new insights about the pedicle of its compound flap have been found, showing that it has the same pedicle of the scapular flap. In the end, Tansini's flap should be more correctly considered as a compound musculocutaneous scapular flap.

Unilateral cleft lip repair during charity missions: a consideration about simultaneously lip and nose repair.

AIM: Cleft nose is an important sequela after primary cheiloplasty in cleft lip patients. Not touching the cleft lip nose in primary cleft lip repair was dogmatic in the past, although it meant severe functional, aesthetic, and psychologic problems for the child. Authors present their experience in one step lip, septum and nasal tip repair for this patients population. METHODS: From March 2012 to January 2013, during charity missions organized in Africa, 56 patients affected by cleft lip deformity and sequelas of previous cleft lip surgery were operated. RESULTS: Two complications were recorded. A good nostril symmetry was reached in all the cases. CONCLUSION: Authors present their experience in one step lip, septum and nasal tip repair for unilateral cleft lip patients. The big lack of this study is the absence of a long follow-up due to the surgery performed during charity missions. Thanks to the recent papers published in literature we can state that primary septal repositioning is a safe adjunctive technique to primary lip closure, although this operation reduces the psychosocial consequences of an otherwise uncorrected cleft nose deformity, it does not necessarily eliminate the need for a future operation.

An improved method of supercharged transposed latissimus dorsi flap with the skin paddle for the management of a complicated lumbosacral defect.

OBJECTIVE: Treatment of non-healing wounds of lower back often poses a powerful challenge. We present one of the first report of treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle. CASE REPORT: We report a case of a 59 year-old man with myeloma of the sacral spine who underwent radiotherapy and chemotherapy and subsequently, laminectomies and placement of hardware for ongoing paresis and spine instability. Then, he developed an open wound and osteomyelitis of the spine with culture positive tuberculous granulomas. After multiple surgical debridement, he presented to our service and was treated with a single stage debridement followed by the performance of a latissimus dorsi musculocutaneous flap based on paraspinal perforators and supercharged. RESULTS: This solution, allowed for augmentation of blood flow to the muscle with the inferior gluteal artery, provided coverage of the defect resistant to the pressure, and simplified post-operative management of the patient. CONCLUSIONS: Alternative treatment options, including free tissue transfer, posed difficulties in finding suitable recipient vessels near the defect, in inserting the flap so as to restore its original length without compromising blood flow, and in postoperative care of the patient. Treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle may represent a milestone procedure for complicated lower spine wounds.

Retirada de implantes mamarios y corrección simultánea con colgajo dermoglandular inferior. Técnica de mastopexia con autoprótesis / Breast implant explantation and simultaneous correction with inferior dermoglandular flap authoprosthesis technique

Los cirujanos plásticos nos enfrentamos cada vez con más frecuencia en nuestra consulta a pacientes que desean o necesitan retirar sus implantes mamarios. Algunas de estas pacientes rechazan la idea de un reemplazo protésico, pero son exigentes con el resultado cosmético postoperatorio. Describimos la técnica empleada en 68 casos consecutivos y los resultados que hemos obtenido al tratar las secuelas en la mama tras la retirada de los implantes, fundamentalmente una disminución de volumen asociada a ptosis y excedente cutáneo. Esta técnica se basa en la extracción de los implantes y correccion mamaria simultanea con colgajo dermoglandular inferior que denominamos "autoprotesis" asociado a injerto graso simultáneo. Los resultados logran mejorar la forma, proyección y conificacion de la mama tras la retirada de los implantes, con un alto grado de satisfacción por parte de las pacientes (AU)

Plastic surgeons are frequently faced during consultation with patients who want or need breast implant explantation. Some of these patients reject the idea of a prosthetic replacement, but are demanding with the postoperative cosmetic result. We describe the technique used in 68 consecutive cases and our results to deal with breast alterations after breast implant explantation, leaving a decreased mammary volume, ptosis and a loosy cutaneous excedent. With this technique of explantation and simultaneous breast correction with de-epithelialized dermoglandular flap, "authoprosthesis", associated with simultaneous fat grafting, we can get a good result regarding the shape, projection and coning of the explanted breast, with high patient satisfaction (AU)

A study of postural changes after abdominal rectus plication abdominoplasty.

PURPOSE: Factors such as body masses and humour are known to influence human posture. Abdominoplasty, which causes a sudden change in body masses, significantly improves body image and self-esteem. The aim of this study was to assess postural changes after abdominoplasty by studding the position and orientation through space of the body and the centre of pressure. METHODS: Patients affected by excess abdominal skin and/or significant abdominal muscular anterior wall laxity due to undergo an abdominoplasty were enrolled. Posture was evaluated both before and for 1 year after surgery by quantifying the centres of mass, using the Fastrak™ system, and the centre of pressure, using stabilometry. The Wilcoxon signed-rank sum test was used to compare changes. RESULTS: Forty-six patients were enrolled. A retro-positioning of the pelvis with a compensatory advancement of the head and shoulders, confirmed by the baropodometric analysis, was evident in the early post-operative period. The biomechanical system subsequently stabilized, achieving a state of equilibrium 1 year after surgery. CONCLUSIONS: We believe that the change in posture following abdominoplasty is a consequence of both surgery (changes in body masses) and psychological factors that influence posture. Indeed, redundant abdominal skin and abdominal muscular anterior wall weakness are often associated with kyphosis since patients try to hide what they consider to be a source of embarrassment. The discovery of a new body image eliminates dissatisfaction, reduces anxiety and increases self-esteem, which provide psychological and physical benefits that improve the quality of life.

Superficial leiomyosarcoma of the glans: report of a case and literature review.

Primary leiomyosarcomas of the penis are rare. Clinically and pathologically, these tumors fall into two groups: superficial and deep. Superficial lesions usually are low grade and show a limited tendency toward distant metastasis. In contrast, deep-seated tumors usually show a more aggressive behavior associated with a poor prognosis. A 62-year-old man with a superficial leiomyosarcoma of the glans penis is reported.

Correction of tuberous breast with small volume asymmetry by using a new adjustable implant.

BACKGROUND: The tuberous breast syndrome is a rare anomaly of breast shape, which can be associated to volume breast asymmetry. We report our caseload in the correction of tuberous breasts with small volume asymmetry by using the Muti's technique associated to the implantation of a new adjustable implant. AIM: Purpose of the study is to evaluate the efficacy of treating tuberous breast deformity with two different types of implants (a textured round high profile cohesive I implant in the larger breast and a Spectra™ implant in the smaller breast). PATIENTS AND METHODS: Since May 2008, patients affected by tuberous breast combined to small breast volume asymmetry were enrolled in a prospective study. After gland deformity correction, the adjustable implant was positioned in the smaller breast. A textured round implant was positioned in the contralateral breast. Standard pictures were taken before surgery and during follow-up visits over one year. A visual analogue scale (VAS) scale was used to evaluate patients' and external physicians' judgment. Standardized objective measurements of breast and chest were also taken. Statistical significance of any value variation was assessed with the Wilconxon's rank sum test. RESULTS: Eleven patients were treated with the proposed surgical approach. VAS scores from patients and external physicians were high. Deformity correction was obtained in all patients as evidenced by the significant modifications of objective measurements. No major late complications occurred. CONCLUSIONS: The new adjustable implant provides a reliable corrective option for hypoplastic tuberous breasts with small volume asymmetry. This device allows intra-operative modification of implant volume according to breast volume discrepancy. Although our findings are satisfying, a longer follow-up is required to evaluate long term results.

New head-mounted miniaturized microscope in hypospadia surgical correction.

AIM: The aim of this paper was to report our experience using VarioscopeÒM5 in hypospadia surgical correction. To suggest the use of microsurgical principles that can result in the successful repair of hypospadias with a few complications. METHODS: Forty-three patients (age 12-16 months), affected by hypospadia, underwent longitudinal dorsal preputial island flap (Scuderi's technique) surgical procedure. All the procedures were performed with Varioscope®M5. This new device is a head-mounted miniaturized microscope which combines a microsurgical microscope illumination and magnification with the freedom of loupes. RESULTS: In 39 (91.1%) of the patients the postoperative course was uneventful. One patient (2.3%) developed urethral fistula and a second intervention was necessary to correct it. He was affected by fourth degree hypospadia. In 3 patients (6.6%) we observed a mild stenosis. Urethral strictures were dilated during multiple sessions, by weekly introduction of catheters of progressively increasing caliber. At 3 months after surgery all urethral strictures had been solved by non surgical treatment, thus decreasing complication rate of the surgical procedure from 8.9% to 2.3%. Evaluation of flow rate was repeated at 3 weeks, 6 and 12 months. The aesthetic outcome was evaluated by the parents on a VAS scale. Results were judged optimal (8-9 out of 10). CONCLUSION: In order to achieve a better aesthetic and functional outcome and to reduce complications we deem a perfect flap dissection and anastomosis necessary. A well lighted and magnified surgical field is essential to achieve the best result due to the small anatomical structures involved in the surgical technique we have adopted. The Varioscope®M5 offers essential advantages in this regard.