Multimodal approach in a patient with Fournier's gangrene during the coronavirus pandemic.

Fournier's gangrene (FG) is a polymicrobial necrotizing fasciitis involving the external genitalia and perineal region. It preferentially affects men, with a mortality rate of approximately 40%. Early diagnosis, surgical debridement, appropriate antibiotic therapy, and hyperbaric chamber treatment increase the therapeutic success. The purpose of this clinical report was to emphasize how a multimodal treatment and the tenacity of the health professionals involved in the era of the coronavirus pandemic with considerable health and logistical difficulties can lead to the complete recovery of patients suffering from FG.

Metastases to the breast. A clinical series from a single institution experience with review of the literature.

INTRODUCTION: Breast metastases although rare are challenging for diagnostic difficulties and management. Treatment differs according to morphological, immunophenotipycal and biologic features of the primary tumor and their general behaviour is extremely different compared to primary breast cancer. The most frequent primary tumors include melanoma, lymphomas, gynecological, pulmonary, head and neck, gastroenteric and urinary tract cancers. Patient's prognosis is poor being generally associated to disseminated systemic disease with limited survival despite the effects of systemic treatment. PATIENTS AND METHODS: We report the analysis of the diagnostic and therapeutic approach on the institutional experience of four cases of breast metastases originating from melanoma, pulmonary adenocarcinoma and differentiated thyroid carcinomas. CONCLUSIONS: The management of breast secondarisms requires focused diagnosis and evaluation in order to provide an adequate treatment with a multidisciplinary approach especially when the primary tumor is unknown. KEY WORDS: Breast metastases, Melanoma, Pulmonary, Thyroid.

Deep burn of hand and forearm treated by abdominal wall flap. A case report.

AIM: Post-traumatic hand and forearm defects always represent a challenge for reconstructive surgeons, especially when multiple structures are involved, because of a high rate of amputation. MATERIAL OF STUDY: A 21 years old woman arrived to the E.R. with a complex crush-burn trauma of the upper limb caused by an accident with an industrial ironing machine, resulting in a ulnar bone fracture, ulnar artery laceration and a wide burn of the dorsum of the right forearm. RESULT: We achieved toTAL limb salvage with coverage of the "nobles" structures of the forearm. DISCUSSION AND CONCLUSIONS: Different reconstructive methods have been used over time to treat these defects focusing the attention on both functional and cosmetic aspects. The abdominal pedicle flap was one of the achiest reconstructive methods for hand and forearm defects. In an era in which microsurgery takes the lion's share, some basic procedure may be helpful, especially in certain cases. In this study the authors reported a case of a young woman with a complex trauma of the right arm resulting from an occupational accident.

Poland syndrome: an algorithm to select the appropriate chest wall surgical reconstructive treatment.

AIM: Poland syndrome is a constellation of rare congenital anomalies of the chest wall, with or without alterations to the ipsilateral superior extremity. Actually Foucras' classification is commonly used to choose the most appropriate surgical treatment, but often only a radiological classification proves unsatisfactory in order to achieve the best aesthetic result. MATERIAL AND METHODS: Since November 2006 in our institute have been treated 6 patients (3 M, 3 F) with Poland Syndrome affected by only chest wall and/or breast deformities. RESULTS: We treated 6 patients opting for different surgical procedures, depending on the deformity detected. We experienced only one procedural complication, a fat necrosis with superior migration of the prosthesis, successfully managed. DISCUSSION: Surgical alternative treatments of the Poland's abnormalities of the chest wall are independent from the corrective surgery of the ipsilateral affected forearm ad hand. Surgeons should be able to develop an operative plan to address aesthetic goals while preserving muscular functionality. Indeed surgical techniques should be minimally invasive and possible available in every hospital structure. CONCLUSIONS: This study has been designed to review a series of surgical options of breast reconstruction in patients with Poland Syndrome in order to develop a new flow chart to plan the best surgical choice analyzing only breast/chest wall deformities according to Blondeel's point of view about reconstruction of the new breast and thoracic wall. KEY WORDS: Breast reconstruction, Poland syndrome.

Commissural localization of squamocellular carcinoma of the lip Our experience.

AIM: Lip cancer is the most common malignant tumour of the oral cavity and the oral commissure is the origin of the tumour in 6% to 8.5% of cases. Reconstruction of oral commissure defects aims at securing oral competence and providing an acceptable appearance. Satisfactory reconstruction of defects affecting the lip commissure is always challenging. MATERIAL OF STUDY: The authors present a selected group of 22 patients, who, between November 2005 and 31st October 2012, underwent reconstruction for primary or secondary defects involving the oral commissure. RESULTS: The results were generally satisfactory, both functionally and cosmetically. The patients had been followed up for 5 years. CONCLUSIONS: All patients had excellent oral competence during rest, speaking and eating. Good sphinteric function was obtained in early postoperative days. No drooling or air leakage. The aesthetic results were good in all patients.

Evaluation of the sensitivity after reduction mammoplasty. Our experience and review of the literature.

AIM: The preservation of the sensitivity of the nipple-areola complex after reduction mammoplasty is an important goal of the modern surgery. The aim of this paper is to evaluate the differences in the recovery of sensitivity after reduction mammoplasty using different techniques. MATERIAL OF STUDY: Using the Semmes-Weinstein monofilament the sensitivity was evaluated in 64 patients undergone to a bilateral reduction mammoplasty: 36 were treated with inferior pedicle technique and 28 with a superior pedicle techniques. The evaluation of the sensitivity was performed in nine points: the nipple, the four quadrants of the areola and the 4 quadrants of the skin around the areola both in the preoperative and at 3 weeks, 3, 6 and 12 months postoperatively. RESULTS: The major alterations were found in the sensitivity of the nipple: the major deficiencies were seen in women treated with a superior pedicle techniques. Minor differences were found about the sensitivity of the areola and periareolar skin. CONCLUSION: The techniques which provide the preparation of a glandular flap with superior pedicle have an increased risk of altering the innervation of the nipple-areola complex. The preparation of a glandular flap with inferior pedicle allows the restoration of the pre-operative sensitivity in 6-12 months. KEY WORDS: Breast sensitivity, Reduction mammoplasty, Sensitivity alteration.

Reconstruction of post-traumatic losses of substance of the scalp: our experience.

AIM: The reconstruction of post-traumatic losses of substance of the scalp is very difficult due to the unique characteristics of the scalp. The purpose of this paper is to evaluate the results obtained with several techniques in order to identify the most appropriate. METHODS: We treated 19 patients, 11 men and 8 women aged between 19 and 81 years, with post-traumatic loss of substance of the scalp from January 2006 to June 2011. The chosen treatments were the direct closure and the use of local flaps, the latter combined or not with the graft of the donor area and the post-operative correction of alopecic area with tissue expansion. RESULTS: None of the patients developed severe complications and all flaps were viable. The aesthetic results were variable, between good and satisfactory according to the technique used. CONCLUSION: The local flaps represent a good choice for the treatment of post-traumatic losses of substance of the scalp, restricting the use of direct suture and the use of skin grafting only in selected cases. Tissue expansion is a good choice for the revision of alopecic and cicatricial areas.

The use of local flaps in the one-step nose reconstruction after cancer resection.

PURPOSE: Purpose of this study is to assess different surgical techniques, comparing them in order to remove nasal skin cancer by restoring the anatomy and the function of the respiratory system without neglecting the aesthetic result. METHODS: A total of 107 patients were enrolled in the study between January 2006 and December 2012. We compared the results obtained using 23 front-glabellar flaps, 30 bilobed flaps, 27 nose-cheek flaps, 15 sliding flaps, 12 frontal island flaps. RESULTS: We obtained the oncological radicality with good aesthetic results. There were no infections and no sensory (numbness and tenderness) and motor abnormalities of the facial nerve. None of the used techniques has lead to scarring ectropion or to alteration of the nasal filter. CONCLUSIONS: The best nasal reconstruction mostly depends on skin cancer location and on the amount of tissue to be removed to definitely eradicate the neoplastic lesion; during the planning of a nasal reconstruction we also must assess adjacent tissue characteristics, the presence of fixed structures and the donor skin area (color, thickness, pils, etc) . Using these parameters we have chosen for the ala the nose-cheek flap, for the dorsum the front-glabellar flap, the bilobed flap and the sliding flap (lateral region) and for the tip both the frontal island flap and the bilobed flap.

Reconstruction of the traumatic eyelid injuries: a 6-years experience.

AIM: Our aim is focused on the management of eyelid injuries and on the chose different techniques for the reconstruction. The reconstructions of the upper eyelid and lower eyelid should be based on both functional and cosmetic aspects. MATERIAL OF STUDY: We looked at 47 patients from 2005 to 2011 with eyelid injuries. All patients were subjected to a surgical treatment. RESULTS: After a median follow-up from one to five years, in all cases the skin coverage was reinstated and mobility was restored, thereby adhering to the principles of both morphological and functional reconstruction. DISCUSSION: Eyelids are complex structures and pose a challenge for reconstruction. They play an important role in protecting the globe from trauma, excessive light and in maintaining the integrity of tear films and moving the tears toward the lacrimal drainage system. Concerning reconstruction by means of flap, the main principles dictate that with this procedure the new coverage will appear as much as possible, "like" the original tissue. CONCLUSIONS: There are different techniques available for reconstructions of defects of eyelids. The availability of tissues, technical expertise and the specific needs of the patient have to kept in mind before choosing a particular method. Compared with other frequently used techniques, the nasal chondromucosal flap is a one-stage operation, does not damage the lower lid, and provides a thin, mobile eyelid with an anatomically complete reconstruction.

Negative pressure dressing in split-thickness skin grafts: experience with an alternative method.

BACKGROUND: The use of negative pressure in the dressing of splitthickness skin grafts has been shown to promote healing by a variety of mechanisms, including a decrease in interstitial edema, an increase in perfusion, and a decrease in bacterial colonization. METHODS: An observational study was performed on 52 patients at the Department of Plastic Surgery, University of Perugia in Perugia, Italy, undergoing split-thickness skin grafting for acute wounds after trauma and for chronic wounds, such as pressure ulcers and diabetic wounds. The dressing used consisted of a single foam sheet, a conventional disposable closed-system suction drain, and an adhesive dressing. RESULTS: In all patients, there was a 95% take of the graft, with 5% of partial loss. There were no significant complications encountered. CONCLUSIONS: Negative pressure wound therapy is an innovative and commercially successful concept for the management of difficultto- treat wounds of nearly every etiology, and the authors' technique is an alternative to commercially available negative pressure dressings..

Cephalic traumas with lacrimal apparatus involvement. Our experience.

PURPOSE: The involvement of the lacrimal ducts in the extreme cephalic trauma is an infrequent condition. A correct diagnosis and appropriate management of injuries of the lacrimal system are essential to prevent the onset of post-traumatic epiphora. METHODS: In the last 5 years, 37 patients were treated for lacrimal apparatus injury as a result of cephalic trauma: in 16 there was an isolated lacrimal injury and in 21 were documented fractures combined with lacrimal damage. RESULTS: In 16 patients who had only deep lesions, was performed a reconstruction after location lesion localization, and only in 4 cases, because of the gravity of the lesion, it was decided to perform a reconstruction in a second time. In the remaining 21 patients the facial fractures were treated before lacrimal injuries, whose reconstruction was carried out on a second time. CONCLUSIONS: The reconstruction of the cephalic district has to be based on the restoration of morpho-functional component and on the identification and treatment of lacrimal injuries. The reduction of fractures in our view should start from the lateral area (centripetal reconstruction) allowing to have a guide for alignment of the fracture lines. The objectives to be achieved in a facial trauma are therefore three: the maintenance of vital functions, the recovery of the function and the restoration of morphological and functional prior to the event.

Surgical treatment of upper eyelid coloboma: our experience.

AIM: The purpose of this paper is to evaluate the results obtained in the surgical treatment of upper eyelid coloboma with methods that do not involve a prolonged occlusion of the eye. MATERIAL OF STUDY: We treated five patients aged between 7 months and 21 years; the surgical techniques adopted were the direct closure (2 patients), the full-thickness graft from the contralateral upper eyelid (2 patients) and the nasal chondromucosal flap (1 patient). RESULTS: The results were good in all patients with vitality of all grafts and flaps; also absent were hematomas, seromas and infections. None of the patients developed amblyopia and lagophthalmos. DISCUSSION: The use of these methods prevents the development of some complications, such as amblyopia, occurring with the use of other techniques, as shown in the literature. In addition, allowing the reconstruction with similar tissues or very flexible and thin tissues provides greater functionality to the new eyelid. CONCLUSIONS: When possible, early intervention with the use of the described techniques will provide good results in the short and long term, allowing to avoid minimal complications which may arise from a prolonged occlusion of one eye.

[Reconstruction of full-thickness loss of substance of lower lip. Our experience]. / Ricostruzione delle perdite di sostanza a tutto spessore del labbro inferiore Nostra esperienza.

AIM: Many methods have been described for the reconstruction of the lower lip, but each has its own advantages and its disadvantages. The purpose of this study is to evaluate the results obtained with the use of different methods in order to choose the most appropriate method, according to the characteristics of the loss of substance. METHODS: From January 2006 to March 2011 were treated 110 patients with full-thickness loss of substance of the lower lip using various techniques: direct closure in small losses of substance (20 patients), Abbe flap (14 patients), Johanson technique (12 patients), Gillies fan flap (9 patients), Estlander flap (8 patients), Mc Gregor flap (11 patients), Karapandzic flap (18 patients), the nasolabial flap by Von Bruns (10 patients) and Bernard-Burow flap modified by Webster (8 patients). RESULTS: All flaps were vital and there were no cases of necrosis, infection, seromas or hematoma. Among the main complications, there was a delay in wound healing in 11 patients and the development of microstomia, of variable degrees, in 9 patients. The results from the aesthetic point of view were between good and satisfactory. CONCLUSIONS: The extension of the loss of substance is the main criterion that should direct the choice of an appropriate surgical technique: for larger defects reconstruction is less than optimal and obtain an adequate sphincter function is the main goal to achieve also with the use of near tissue.

[Polythelia and supernumerary breast. Personal experience and review of the literature]. / Politelia e mammella sopranumeraria. Nostra esperienza e revisione della letteratura.

AIM: Our study focuses on the approach, management and treatment of patients with polythelia and supernumerary breast and the target is the search for a treatment algorithm for these diseases. MATERIAL OF STUDY: We considered at 18 patients treated from 2006 to 2011 for breast congenital anomalies in excess. 14 surgical procedures were performed, 8 for supernumerary nipple excision (1 case associated with Poland Syndrome) and 6 for accessory breast ablation. All patients were aged between 15 and 34 years and belonged to both sexes. RESULTS: The breast tissue it was detected fibrocystic mastopathy in 5 cases of polimastia. In the remaining cases the nipples and mammary tissues were normal. After a median follow-up from one to five years, we obtained in all cases not only an excellent aesthetic result but also a psychological. DISCUSSION: The supernumerary breast tissue is not just a cosmetic problem, it is also subject to the same pathological lesions that are observed in a normal breast. In view of the potential malignant transformation of anomalous breast incidentally, early and accurate diagnosis is required as well as its monitoring over time. CONCLUSIONS. We therefore believe that surgical approach is always necessary in cases of polimastia, while considering options in the treatment of polythelia, where it becomes crucial if aesthetic and/or psychologically problems in the patient coexist.

[Treatment of ulcer and difficult wounds of the lower limbs: our experience]. / Trattamento delle ulcere e delle ferite difficili dell'arto inferiore. Nostra esperienza.

AIM: The purpose of this study is to evaluate the results obtained using traditional and advanced dressings, platelet gel, vacuum therapy and surgical techniques (grafts, flaps and dermal substitutes) in the treatment of ulcers and difficult wounds of the lower limbs to determine a treatment algorithm. MATERIAL OF STUDY: From January 2006 to September 2010 were performed 428 treatments on 377 patients (203 men and 174 women, age between 32 and 90 years). Both medical and surgical treatments were performed: 61 traditional medications, 149 advanced dressings, 25 with platelet gel, 42 with the vacuum therapy, 16 with surgical debridement, 86 with skin grafts of varying thickness, 8 with dermal substitutes and 42 with surgical flaps. RESULTS: The best results were obtained with the most innovative methods, which showed, on average, a higher healing rate compared to traditional medications. Positive results were also obtained with surgical treatment if properly preceded by a correct wound bed preparation. CONCLUSION: The main characteristic that should guide the choice of therapy is the clinical appearance of the lesion: correct management of all its aspects allows to increase the rate of healing and, when necessary to have recourse to less invasive surgical procedures.

Lateral canthoplasty by the Micro-Mitek Anchor System: 10-year review of 96 patients.

PURPOSE: Lateral canthoplasty is useful to correct lower eyelid malposition, restore eyelid function, and protect the ocular surface. An effective method for fixation of soft tissue in the face, such as the lateral canthus, using the Micro-Mitek Anchor System is presented. PATIENTS AND METHODS: We report our experience in 96 patients who underwent lateral canthoplasty by Micro-Mitek Anchor. One hundred twenty-four lateral canthoplasties were performed, including, senile ectropion, tumors, trauma, cicatricial retraction, and lower eyelid malposition after blepharoplasty. RESULTS: The insertion of a bone anchor requires a limited dissection, and the insertion area can be determined accurately. Using the bone anchor to fixate the lateral canthus to the facial skeleton is an effective way to prevent drooping of the canthus due to gravitational forces. CONCLUSIONS: Lateral canthoplasty using the Mitek Anchor System has the advantage of being an easy technique with accurate placement of the anchor, reducing operating time.

Phase 2 cross-over multicenter trial on the efficacy and safety of topical cyanoacrylates compared with topical silicone gel in the prevention of pathologic scars.

BACKGROUND: Many clinical studies on scar therapy are reported in the literature, but only silicone gel sheeting and corticosteroid injections are supported by accurate prospective controlled studies. This prospective multicenter cross-over phase 2 study tested the effectiveness of a topical cyanoacrylate compared with silicone gel in improving postsurgical scars METHODS: Patients presenting with symmetric breast scars after augmentation or reduction mammaplasty were enrolled in the study. From the same day as stitch removal, the cyanoacrylate was applied on one side every 3 to 5 days and the silicone gel on the other side twice a day for 3 months. Assessments of patients and external observers using a visual analog scale were recorded at scheduled visits during 1 year, and scars were photographed. Objective evaluations included measurements of scar width, length, and elevation. The statistical significance of objective parameter modifications was analyzed using the Wilcoxon test RESULTS: Positive effects of both tested products were observed during the scar maturation process, and final scars of good quality were achieved without any major adverse effect. The topical cyanoacrylate proved to be more efficacious in preventing scar widening, and this result was statistically significant CONCLUSIONS: The tested topical cyanoacrylate had a positive effect on the scar maturation process at least comparable with that of topical silicone gel.

Multicenter study on breast reconstruction outcome using Becker implants.

The use of tissue expanders and implants is the simplest option for breast reconstruction following mastectomy. In the 1980s, Hilton Becker introduced a round, inflatable breast implant that could be used as a permanent implant. Since then, the original implant has been improved in both design and architecture. The new Becker device consists of an anatomical implant composed of 35% cohesive silicone gel in the outer chamber and 65% normal saline in the inner chamber. This multicenter study describes our experience with the new anatomical Becker implants in a large series of patients, in both immediate and delayed breast reconstruction. We reviewed the clinical records of 204 patients who underwent a breast reconstruction with an anatomical Becker-type implant in the sub-muscular position between November 2004 and December 2006. Data on the patients' characteristics, indications for reconstruction, operative technique, device size used, complications, and need for further operations were collected and analyzed. A total of 248 breast reconstructions were performed in 204 patients. One hundred forty-three patients (70%) underwent an immediate reconstruction; in the remaining 61 cases (30%), the breast reconstruction was performed later. The patients' age ranged from 26 to 66 years, with a median age of 47.5 years. The implant was placed unilaterally in 160 women (78.5%) and bilaterally in the remaining 44 (21.5%). Complications occurred in 85 cases (34.2%), in both the immediate and delayed reconstruction groups, and were related to wound healing, bleeding, seroma, and problems with the inflatable expanders. Iatrogenic implant rupture was documented in one case (0.4%). Inflation was impossible in 7 cases (2.8%) as a result of valve obstruction (3 cases, 1.2%) and valve displacement (4 cases, 1.6%). Implant malposition was the most troublesome complication; indeed, 34 patients (13.7%) complained of device malposition. Capsular contracture was assessed in all the patients. Significant capsular contracture (Baker grade III and IV) was detected in 6 cases (2.4%) at the follow-up approximately 1 year after surgery. Breast reconstruction with permanent inflatable expanders is widely acknowledged as a useful technique for breast cancer patients undergoing simple or modified radical mastectomy. The use of this device eliminates the need to replace a temporary tissue expander with a breast implant, thus avoiding a second operation. Although we believe autologous tissues afford the best method of reconstruction in the majority of patients, the results of our study show that expander implant placement may yield a reasonable reconstruction.

Efficacy of topical cyanoacrylates compared to topical silicone gel in the treatment of hypertrophic scars.

AIM: The effectiveness of cyanoacrylates compared to silicone gel in improving healing of hypertrophic scars was evaluated. PATIENTS AND METHODS: Patients presenting hypertrophic scars 6 to 24 months old were enrolled. Asymmetrical scars were treated with cyanoacrylates, linear scars were divided in two parts, one treated with cyanoacrylates, the other with silicone gel. For 3 months, cyanoacrylates were applied every 3-5 days, silicone gel twice a day. Patients' and external observers' assessments were recorded over one year, and photographic records taken. Objective evaluations included width, length and elevation measurements. Statistical significance of parameter modifications was analysed with the Wilcoxon test. RESULTS: A total of 150 patients were enrolled. Positive effects of both tested products were observed without major adverse effects, achieving final scars of better quality. Scar elevation was reduced significantly for both tested products, but apparently more for topical cyanoacrylates. CONCLUSION: Cyanoacrylates have a positive effect on pathological scars at least comparable to that of silicone gel.

Assessment of a new hyaluronic acid filler. double-blind, randomized, comparative study between Puragen and Captique in the treatment of nasolabial folds.

Fillers represent a field of aesthetic medicine under remarkable expansion. Over the past few years, in the USA, there has been a huge increase in the use of fillers, especially for hyaluronic acid (400% in 2004). The causes of this increase have been the greater tolerability of this reabsorbable filler with respect to the others, and its prolonged efficacy in time due to chemical modifications of its molecular structure. In our study, we report the results of a double-blind comparative study between Puragen (latest-generation hyaluronic acid with double cross-linking) and Captique (second generation hyaluronic acid with single cross-linking), in the treatment of nasolabial folds. Each patient received Puragen in one nasolabial fold and Captique in the contralateral fold, at random. Clinical efficacy was assessed independently by the investigator and the patient 2, 4 and 6 months after baseline or when the optimal cosmetic result was obtained. The tolerability assessment was made by the patient (using a daily diary to record any adverse events) for 2 weeks after each treatment, and by the operator 2, 4, and 6 months after baseline. Sixty-eight patients completed follow up at 6 months. From the results obtained in this study, Puragen remained stably in the treated tissues even after 6 months while less satisfactory results were obtained with Captique.