[Intralesional Cryosurgery in the Treatment of Keloids - A Differentiation of Keloid Types for the Improvement of Patient Selection]. / Keloidbehandlung mit intraläsionaler Kryochirurgie.

The overproduction of altered collagen fibers and the overexpression of Tumor Growth Factor-ß must be blocked in order to interrupt the growth process within a keloid scar. This can barely be achieved with the classical therapeutic methods. The results of keloid treatment are difficult to predict and the recurrence rate is usually over 50 %. In addition, some of the procedures used (e. g. irradiation) may induce additional health risks. Intralesional cryosurgery offers a therapeutic alternative that has been evaluated since more than a decade. Our own experience in more than one thousand keloid treatments allows a critical evaluation of the classification in those keloid types, which are recommended to be treated with the technique and those, which may not respond.

A prospective case-control study of non-healing wounds of the lower limbs - the value of biopsies for ulcerating carcinoma.

BACKGROUND: In some leg ulcer patients there is cancer that is responsible for lack of healing of such a wound. AIM: This study was aimed at prospective analysis of histopathology of non-healing wounds (NHWs) in the patient presenting with high and low suspicion for ulcerating carcinoma. MATERIAL AND METHODS: Forty patients with NHWs were enrolled and had been prospectively divided into two groups: 25 patients with high suspicion for ulcerating carcinoma according to their medical history and physical examination, and the second group of 15 patients without suspicion for malignancy (control group). All NHWs were photographed and underwent biopsies. RESULTS: In the control group biopsies did not reveal cancers. On the contrary, in 10 patients (40%) from high suspicion group biopsies revealed cancers: seven basal cell carcinomas (BCCs), one - malignant melanoma, one - Bowen's disease and one - squamous cell carcinomas. Histopathology of six of seven BCCs suggested that non-healing benign wound might have preceded malignancy. We found that leg ulcers which were small (wound area less than 3 cm(2) ), longstanding (duration 24 ≤ weeks), presenting with granulation tissue covering ≥75% of the wound area, with a dull pink appearance of the granulation tissue, or an atypical clinical presentation, can actually be an ulcerating carcinoma. Dull pink granulation tissue or an atypical clinical presentation of ulceration, as a single clinical finding, suggested an underlying malignancy with a statistical significance (71.5% vs. 0%; P = 0.001 and 27.8% vs. 0%; P = 0.0049 respectively). CONCLUSIONS: Prevalence of malignancy, primarily: BCCs in NHWs, may be higher than expected and clinical features suggestive of such a nature of ulcer are an indication for diagnostic biopsy.

Pain evaluation and control during and following the treatment of hypertrophic scars and keloids by contact and intralesional cryosurgery--a preliminary study.

BACKGROUND: Intralesional cryosurgery effectively treats hypertrophic scars and keloids (HSK), but pain experienced by the patient during treatment can limit the application of cryosurgery. OBJECTIVES: To characterize the pain response during cryosurgical treatment of HSK, and to evaluate the pain experienced during contact and intralesional cryosurgery that employs a pain-control protocol. METHODS: Twenty-nine patients (17 women, 12 men) aged 17 years and older (mean ages 31.9±12.5 and 38.9±18.6 years, respectively, P=0.24), who were treated for a total of 36 HSKs by intralesional (n=20; 22 cryotreatments) or contact (n=9; 14 cryotreatments) cryosurgery were evaluated. The pain-control protocol involved oral pain-relief tablets (Dipyrone) and translesional local anaesthesia with Bupivacaine hydrochloride 0.5%. Pain evaluation according to the Visual Analogue Scale (VAS) (0-10 cm) was compared between the two groups at three time points: during cryosurgery, immediately after it, and 4 h later. Scores ≤3 cm were considered to define the 'zone of analgesic success'. These results were compared with control data (contact cryosurgery without a pain-control protocol; n=56). RESULTS: Pain in the intralesional group was significantly lower than that in the contact group during and immediately after cryotreatment. During: mean VAS=1.68±2.21 vs. 5.07±4.01 cm; median VAS=0.5 vs. 5.5 cm, respectively; P<0.0001. Immediately after: mean VAS=1.22±1.77 vs. 5.38±3.81 cm; median VAS=0 vs. 6.0 cm, respectively; P=0.001. The control group had more pain during treatment (mean VAS=5.34±2.31, median=6.0) and 4 h later (mean=3.79±2.35, median=4.0) than the intralesional group (P<0.0001 and P=0.988, respectively). The pain level in the control group during the cryotreatment did not differ from that in the contact group (P=0.988). In the intralesional, contact and control groups analgesic success (VAS ≤3 cm) was achieved in 77.3%, 35.7% and 33.9%, respectively, of cases (P=0.002) during cryotreatment, and in 54.5%, 42.9% and 33.9%, respectively, of cases 4 h after treatment (P=0.24). CONCLUSIONS: The pain-control protocol significantly reduced pain severity to tolerable levels (VAS ≤3 cm) during and following intralesional and contact cryosurgery. Intralesional cryosurgery caused the least pain during and immediately after treatment.

Keloid histopathology after intralesional cryosurgery treatment.

BACKGROUND: Keloid presents a great healthcare challenge. The patients suffer from aesthetic disfiguration and occasionally from pruritus, pain and discomfort. Although various treatments are recommended, a single, highly effective treatment represents a great clinical need. OBJECTIVE: The cellular events and histopathology that follow intralesional cryosurgery were evaluated including cell proliferation, the number of cells expressing fibroblast markers, collagen synthesis and organization and mast cell infiltration. METHODS: Biopsies were collected before and after intralesional cryoneedle procedure. Collagen structure was evaluated with confocal microscopy. Mast cells, blood vessels and cell proliferation were evaluated using immunohistochemistry. RESULTS: Keloids contain abnormally thick collagen bundles, organized in swirls comprising closely bound fibrils. After intralesional cryosurgery, the collagen bundles lost their swirl structure, the thickness of the collagen layer decreased, and the bundles became more compact with less space between the fibres. A clear distinct transition zone separated the treated from the unaffected area. The frozen tissue was devoid of proliferating cells and mast cells whereas the number of blood vessels remained unaltered. Most of the fibroblasts expressed all tested myofibroblast markers although some exclusively expressed one and not the other. Few nuclei were observed in the affected area after treatment and very few of them expressed any fibroblast markers. CONCLUSIONS: Intralesional cryosurgery resulted in major changes in collagen structure and organization. The treatment reduced the number of proliferating cells, of myofibroblasts and of mast cells. These results may explain the reduction in no-response rate and the amelioration of the clinical symptoms after intralesional cryosurgery treatment.

Atypical fibroxanthoma of the scalp following hair transplantation in a 35-year-old male.

Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm of the elderly. This case report presents an atypical case of AFX of the scalp 8 years after hair transplantation in a 35-year-old male patient. Possible synergistic effects of previous sun exposure radiation to the scalp, together with the thermal and radiation injury of carbon dioxide (CO(2)) laser, might explain the mechanisms of the development of AFX at such an early age. To the best of our knowledge, this case report is the first description in the medical literature of development of skin malignancy on a hair-transplanted scalp.

Effect of skin surface temperature on skin pigmentation during contact and intralesional cryosurgery of keloids.

BACKGROUND: This 15-month study was designed to compare the effect of skin surface temperature on skin pigmentation following a single intralesional or contact cryosurgical treatment of keloids. PATIENTS/METHODS: Thirty Caucasian patients with 45 keloids present for more than 6 months were included in this study. Twenty-one keloids were treated by the contact method while the remaining 24 scars were managed using an intralesional cryosurgery technique. The skin surface temperature at the keloids was measured and recorded using a Ni/Cd thermocouple. Four variables of the thermal history were evaluated with the contact and the intralesional methods, namely cooling rate, hold time, end temperature and thawing rate. Assessment of the local hypopigmentation was performed 6 months after the treatment using a pigmentation scale. RESULTS: Significantly slower cooling (6.09 +/- 4.56 degrees C/min) and thawing rates (54.52 +/- 32.17 degrees C/min) were recorded with the intralesional cryosurgery method when compared with the cooling rates (13.47 +/- 9.04 degrees C/min) and thawing rates (89.00 +/- 86.42 degrees C/min) of the contact method (P < 0.000001). The end temperature of the contact technique was significantly cooler (-46.77 +/- 14.74 degrees C) when compared with that of the intralesional method (-15.55 +/- 6.77 degrees C) (P < 0.000001). There was a trend for the hold time of intralesional cryosurgery to be longer (82.67 +/- 138.03 s) than that of the contact method (16.86 +/- 23.49 s) (P < 0.059). A significant difference in skin pigmentation was demonstrated between the two cryosurgical methods. In 91.7% of the keloids treated by the contact technique a significant hypopigmentation was noticed, while no marked hypopigmentation was detected in the skin surface of the keloids treated by the intralesional method (P < 0.0001). CONCLUSION: We hypothesize that the thermal history of the skin surface during the intralesional cryosurgery technique provides a better survival environment for the melanocytes than the contact method, thus producing a lower rate of permanent hypopigmentation and disfiguring.

Electrical impedance scanning for melanoma diagnosis: a validation study.

BACKGROUND: A multicenter study was conducted to test the ability of electrical impedance scanning to differentiate between benign and malignant skin lesions. The performance of a dual electrical impedance scanning/image analysis device was also assessed. METHODS: Electrical impedance scanning measurements of 449 preoperative lesions found on 382 patients and including 53 melanomas from the trunk and extremities were performed. Results were correlated with histopathologic findings. In addition, ABCD parameters for the lesions were automatically calculated by the system. RESULTS: Electrical impedance scanning detected melanomas of the trunk and extremities with 91 percent sensitivity and 64 percent specificity. Moreover, sensitivity of electrical impedance scanning was increased to 100 percent for in situ and thin melanomas of smaller size (n = 27). Visual examination identified as malignant only 67 percent of these early tumors (p = 0.002). Clinical examination detected 96 percent of the larger or thicker melanomas (n = 26), whereas electrical impedance scanning detected only 81 percent of them. Combined electrical impedance scanning and image analysis detected 100 percent of the melanomas, independent of their thickness, and with no significant decrease of specificity. Because of electrical differences between the head/neck and the rest of the body, the assessed electrical impedance scanning parameters were not adequate for the diagnosis of melanomas from the head and neck. CONCLUSIONS: A validation study proved the value of electrical impedance scanning as a noninvasive technique for detection of melanoma lesions of the trunk and extremities, specifically, of in situ and thin type. In addition, image analysis was shown to be a valuable, complementary procedure. New parameters should be designed to optimize the performance of electrical impedance scanning for melanomas of the head and neck.

Evaluation of penile revascularization for erectile dysfunction: a 10-year follow-up.

The objective of this study was to report long-term success rates for penile revascularization (PR) and investigate factors responsible for failures. During the past 10 y, data were obtained on 52 patients who underwent PR. Surgical technique was selected according to preoperative arteriographic findings. The mean age was 28.5 y and the mean follow-up was 70.8 months. Success was defined as satisfactory intercourse without additional therapy. Overall success was 48%. Patients under 28 y showed a 73% success rate vs 23% in the older ones (P=0.0003). Nonsmokers had a 57% success compared to 29% in smokers (P=0.05). The presence of venous leak and type of procedure had an insignificant impact on success (P=0.33 and 0.23 respectively). To conclude, this curative treatment option is limited to a selective population with vasculogenic erectile dysfunction. We found that the cure rate of this procedure is maintained and long-term follow-up shows good results, especially in the young nonsmokers.

Pilot study of a novel treatment for androgenetic alopecia using enriched cell culture medium: clinical trials.

Androgenetic Alopecia (AA) afflicts a large part of the population and of the many treatments available today none is completely satisfactory. Testing the efficacy and safety of a novel topical treatment for AA which is based on cell culture medium supplemented with insulin, thyroxin and growth hormone (CCM). The 48 participants classified as androgenetic alopecia Type II, III or IV on the Hamilton scale, concluded a randomized, vehicle-controlled, double-blind trial of 6 months duration. Under occlusive cover the gel was self applied for at least 3 hours daily. Evaluation was based on hair counts, investigator global assessment and participants self-administered questionnaire. Cessation of hair loss was reported by most participants within 28 weeks, and further confirmed by the hair count (HC) in ~80% of participants. Moreover, as early as 4 months after the start of the treatment, a time dependent increase of up to 50% in HC was observed. The average change in HC between the two groups differed significantly (p=0.007), with values of 4.1% for control and 13.8% for CCM. Following 4 months of treatment, a time dependent increase in HC (>10%) above minimal was observed in 55% of the CCM and 25% of the control and this trend continued. At 6 months 63% of the CCM and 33% of the control group exhibited increase of HC higher than 10%. The average increase in HC in the CCM and the control groups was 17.1% and 8.9% respectively (p=0.035). Self evaluation questionnaires revealed a time dependent increase in satisfaction in the CCMusers compared to the control. While the average score at T2 was similar in CCM and control (2.7 and 2.6 respectively), the score at T6 in the CCM increased to 5.9 and decreased to -0.4 in the control (p=0.007). Global-clinical evaluation following six months treatment revealed significantly (p=0.02) more hair loss in the control group (40%) compared to the CCM (7%) treated group. CCM was found effective in treating androgenetic alopecia in men. It induced cessation of hair loss, increased rate of hair growth and appearance of new hair. No side effects were reported or observed.

Sensitivity and positive predictive values of presurgical clinical diagnosis of excised benign and malignant skin tumors: a prospective study of 835 lesions in 778 patients.

This article reports on the sensitivity and positive predictive value of clinical diagnosis of benign and malignant skin tumors by expert plastic surgeons in an Israeli clinic. Most published reports have focused on the sensitivity of clinicians' diagnoses, a general measure of the physician's skill that does not predict the rate of accuracy of a physician's diagnoses. Our study of 835 lesions in 778 patients, one of the largest Israeli series, assesses the clinical diagnosis of malignant and benign skin tumors and is one of the few that provide information on the positive predictive value, the measure that is of interest to both physicians and patients. The majority of tumors were benign (56.8 percent), 31.6 percent were malignant, and 11.6 percent were premalignant. Among the 474 benign lesions, 46 percent were nevi. The most common nevi subclass was compound nevi (53 percent), 9 percent of the nevi were dysplastic, and 5 percent were blue nevi. The most common malignant tumor was basal cell carcinoma, accounting for 78 percent of malignant tumors. Although sensitivity for clinical diagnosis of malignancy was 91.3 percent, the positive predictive value for clinical diagnosis of malignancy was 71.3 percent. The sensitivity rate for clinically diagnosing premalignant tumors was 42.3 percent, whereas the positive predictive value for these diagnoses was higher (64.1 percent). The sensitivity rate for diagnosis of all benign lesions was 85.9 percent, and the positive predictive value was 94.2 percent. The sensitivity rate for diagnosis of all nevi was 87.6 percent, and the positive predictive value was 85.7 percent: i.e., only seven of the 218 pathologically proven diagnoses of nevi (3.2 percent) were falsely diagnosed as malignant lesions. Even more interestingly, five of the 223 clinical diagnoses of nevi (2.2 percent) were pathologically proven to be malignant melanomas, and seven were found to be premalignant lesions (3.1 percent). It was concluded that publications which report only on the sensitivity neglect to provide information of interest regarding the positive predictive value. Often, positive predictive value is qualitatively different from the sensitivity, and thus relying only on the sensitivity may lead to incorrect evaluation of a clinical judgment, which may result in erroneous surgical decisions.

Stimulated healing of recalcitrant wounds by topical application of enriched cell culture medium: a clinical report.

This study was designed to test the efficacy of enriched cell culture medium as a wound dressing. The rationale was to create within the wound space an optimal microenvironment, conducive to cellular proliferation, vascular granulation tissue formation, and epithelialization. This study was performed on various wounds that failed to respond to previous conventional treatments.A total of 288 wounds were within the inclusion criteria, with only contaminated and neoplastic wounds excluded. Most of the patients (80 percent) were ambulatory, and the wounds were examined by the attending physician once every 7 to 14 days at an outpatient clinic. The remaining 20 percent of patients were admitted to the study while hospitalized. Cell culture medium MCDB, supplemented with insulin, thyroxin, and growth hormone, was gelled. The gel was self-applied once a day to freshly washed wounds, covered with a gauze pad, and anchored with netting. Healing started 7 to 14 days after the initiation of treatment with enriched cell culture medium. However, the criterion for success of the treatment was determined on complete wound closure, which was achieved in 189 of 288 wounds (65.6 percent). Wound closure was correlated with the initial wound volume, stage, and origin. The average time required for closure of wounds caused by systemic pathologies (n = 181) and those based on regional status (n = 107) were 12.0 and 4.4 weeks, respectively, compared with 290 and 10.3 weeks of the previous conventional treatment. In 19 extensive wounds, when vascularized granulation tissue was established, a successful surgical closure was attained. Most wounds of patients who did not continue the enriched cell culture medium treatment (34.4 percent) manifested reduced wound volume, ranging from 11 to 98 percent of initial volume. Discontinuation of treatment was associated with difficulties in reaching the clinic for the weekly examination, rather than for reasons directly related to the treatment itself, and occurred significantly earlier during the treatment period.Thus, enriched cell culture medium was effective in stimulating wound healing in recalcitrant wounds. The healing was rapid with minimum scarring and pain. No side effects or allergic reactions were reported or observed.

Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair.

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.

Improved vitality of experimental random dorsal skin flaps in rats treated with enriched cell culture medium.

A defined, serum-free cell culture medium supplemented with nonsteroidal anabolic hormones, insulin, thyroxin, and growth hormone was found to accelerate wound healing by stimulating vascularized granulation tissue formation, epithelialization, and angiogenesis. The aim of this work was to study the effect of cell culture medium on the survival rate of cephalically based random dorsal skin flaps in an animal model. A total of 77 Sprague-Dawley rats were randomized into five treatment groups: pharmacologic delay with cell culture medium, flap enhancement with cell culture medium, surgical delay, biological delay with saline, and control. Statistically significant differences in distal flap necrosis were found among all groups (p<0.003). The rats treated with cell culture medium before flap elevation showed a significant increase in flap viability: a survival rate of 83 percent, compared with the control group, which demonstrated a survival rate of only 58 percent (p<0.0001). The surgical delay and the groups treated with cell culture medium yielded similar results with no significant difference between them. This study indicates that preoperative injection of cell culture medium may play a role in decreasing skin flap necrosis.

Striae distensae of augmented breasts after oral contraceptive therapy.

A case of striae distensae (SD) of bilateral augmented breasts following oral contraceptive therapy is presented. Striae maturation and the prevention of additional skin marks was achieved with immediate cessation of oral contraceptive pill therapy and long-term daily topical application of tretinoin cream. It is suggested that patients who are candidates for breast augmentation surgery should be informed of the possible risk of developing SD if they are taking or planning to take the contraceptive pill.

PIP: This is a descriptive report on the development of striae distensae (SD) on augmented breasts following oral contraceptive (OC) therapy. The subject was a 17-year-old nulliparous girl who had undergone bilateral augmentation mammoplasty and developed SD following low-dose OC therapy for 4 months after surgery. The pathogenesis of SD seems to be multifactorial and includes mechanical stretching, age, hormonal effects, and genetic and familial predisposition. Certain changes in the endocrine system also have a role in the development of the striae. In this case, the stretch marks began when the patient started taking the Mercillon contraceptive pills and matured after she ceased to take the birth control pills and began a long-term daily application of tretinoin cream. While patients who are candidates for augmentation mammoplasty should be informed of the possible risk in taking OCs, there is no conclusive evidence that there is a relationship between the use of birth control pills and the development of striae distensae following augmentation mammoplasty.