[Fournier's gangrene: remarks on two clinical cases]. / Le gangrène de Fournier: remarques sur deux cas cliniques.

Fournier's gangrene is a genital and perineal necrotizing fascitiis with a rapid evolution. It's an affection caused by aerobic and anaerobic micro-organisms, eventually associated with a superinfection by micetes. It has characterised by a deep oedema associated with lancinating pain and itching in external genitalia, rapidly evolves to perineal tissues necrosis and purulence. At this stadium patient's general conditions are still serious and patient may be comatose. When toxaemia is over, demarcation of necrotic areas can be remarkable and granulation start growing. Fournier's gangrene seems to be related to an ischemic necrosis caused by obliterative endoarteritis and thrombosis of internal pudendal and deep and superficial external pudendal artery. The infection gateway may be subcutaneous tissue lesion associated to trauma or surgical procedures in immunodeficient organism. Diagnosis is mainly clinical but a superficial ecography could be useful to demonstrate thickening in subcutaneous tissue with normal testicles. Both of them were middle aged males, heavy smokers, affected by hypertension and COPD. In both cases there was polymicrobial Gram positive bacterial infection. Antibiotic systemic therapy and topic therapy were administered. The patient also received hyperbaric oxygen therapy. Thirteen days after the admittance, the infection was defeated and we could start the surgical cover. To cover the scrotal wound we have used split-thickness skin grafts taken from the right thigh. These grafts took at 100% and the patient was discharged seven days after surgical operations. Follow-up at six months and at one year showed any functional limitation and a good aesthetic result.

The distally based superficial sural flap: our experience in reconstructing the lower leg and foot.

The treatment of soft-tissue defects of the lower third of the leg and foot is often an awkward problem to tackle because of the frequent involvement of muscle, tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them and by the small quantity of local tissue available for reconstruction. The authors present their experience with the use of sural flaps for the treatment of small- and medium-size defects of the distal region of the lower limb. The flap used was a distally based fasciocutaneous flap raised in the posterior region of the lower two thirds of the leg. Vascularization was ensured by the superficial sural artery, which accompanies the sural nerve together with the short saphenous vein. The authors treated 18 patients (12 men and 6 women) from May 1997 to August 1999 at the Division of Plastic Surgery, University of Turin, Italy. Superficial necrosis without involvement of the deep fascia (which was grafted 1 month later) occurred in 1 patient of the 18 treated. In another 2 patients, defects were found in the flap margins, but no additional surgical revision was necessary, and recovery occurred by secondary intention. In every patient the sural flaps provided good coverage of the defects, both from a functional and an aesthetic point of view. The major advantages of this flap are its easy and quick dissection. Because the major arterial axis is not sacrificed, this flap can be used in a traumatic leg with damaged major arteries.

[Cranioplasty with polymethylmethacrylate. The clinico-statistical considerations]. / Cranioplastica con polimetilmetacrilato. Considerazioni clinico-statistiche.

BACKGROUND: The main purpose of the reconstruction of the cranium is the protection of the brain. Besides we have to consider important functional and aesthetic necessities in order to achieve satisfactory results. METHODS: Thirty-six clinical cases, operated from November 1991 to June 1996, in which the reconstruction of the cranial vault is carried out by a polymethylmethacrylate acrylic resin are analysed. The causes and locations of the most common bone defects and the main indications for reconstruction are examined. While the repair of the osseous gaps caused by neoplasms is immediate, in the traumatic occurrences, in order to reduce the probability of infectious complications, an average time of 11 months elapsed from the first operation. The surgical technique, with slightest alterations, is the same in all the presented cases, preparing the acrylic resin straight on the operating table. The resin, moulded and adapted to the defect until its complete hardening, presents, thanks to its properties, manifold advantages (and few real disadvantages). RESULTS: The results, in terms of complications, are very satisfactory, with an infectious rate of 2.7%. Besides, in one third of the patients, a considerable clinical improvement after the repair has been observed. CONCLUSIONS: According to personal experience, it is possible to affirm that polymethylmethacrylate, with its remarkable plasticity and stability in time, can always guarantee a satisfactory functional and aesthetic result.

Distally based fasciocutaneous flaps: a versatile option for coverage of difficult war wounds of the foot and ankle.

Early reconstructive treatment of war-related lower extremity injuries can be feasible even when evacuation to ideal tertiary facilities is impossible. However, in such instances, lengthy procedures considered "state of the art" in the everyday civilian practice of plastic surgery are often impractical, and alternative options need to be sought. Undelayed distally based fasciocutaneous flaps of the leg have recently been used in 12 cases of extensive defects of the foot due to antipersonnel mine injuries. All patients, treated during the conflict in Bosnia-Herzegovina, were smokers and were between 17 and 45 years of age. No preoperative arteriography or Doppler was available. One flap was totally lost, and two others suffered tip necrosis. All other cases healed uneventfully. We were impressed at the reliability of distally based fasciocutaneous flaps, even with length-to-width ratios of up to 5:1, and even after distal deepithelialization or tubing of the pedicle. The whole foot can be reached when the appropriate lateral or medial based flap is selected. Obvious disadvantages are the grafted secondary defect of the leg and the lack of sensation, although the latter is a common feature shared by most other flaps to the foot. Also, free-muscle transfer is preferable for very deep defects with extensive bone loss. However, for the ease of dissection, versatility, and short operating time, distally based fasciocutaneous flaps find a definite place in reconstructive trauma surgery.

Liposome-delivered 131I-labelled Zn(II)-phthalocyanine as a radiodiagnostic agent for tumours.

131I-Zn(II)-phthalocyanine (ZnPc) incorporated into unilamellar liposomes has been systemically injected to mice bearing a transplanted MS-2 fibrosarcoma. Biodistribution studies show that the pharmacokinetic behaviour of 131I-ZnPc is very similar to that defined for the parent molecule ZnPc including a serum half-life of ca. 12 h, a high recovery from liver and spleen and minimal accumulation in kidney and brain. The most important pharmacokinetic parameter is represented by the high tumour/ muscle ratio of 131I-ZnPc concentration (ca. 9 at 24 h post-injection). These results suggest the possible use of the radiolabelled derivative for a real-time non-invasive monitoring of the ZnPc concentration in the tumour and peritumoural tissue during photodynamic therapy.

Brachial plexus surgery. An historical perspective.

Clinical observations on brachial plexus palsy belong to the last decades of the 19th century. True brachial plexus surgery is even more recent, starting with the beginning of this century. Surgical endeavors on the plexus have been varied and have met with alternating fortunes, undertaken by surgeons in a fascinating blend of sheer enthusiasm and deep pessimism.

Carbofilm-covered prostheses in plastic surgery: preliminary observations.

The optimal interface between an implant and the host organism is that which minimizes uncontrolled and irregular growth of fibrous tissue around the foreign material. One way to achieve this goal is to coat the outer surface of the implant with a biocompatible material. A thin film of turbostratic carbon (Carbofilm, Sorin Biomedica, Saluggia, Italy) can be applied as a thin coating on tissue expanders and breast implants made of silicone elastomers. The success of biologic trials with such implants in rats and cytologic studies with murine and human fibroblasts encouraged us to employ the Carbofilm technology in clinical situations. Preliminary results indicate that Carbofilm-coated implants satisfy the requirements of an ideal alloplastic material and induce a minimal periprosthetic inflammatory reaction, with the formation of a thin, soft, pliable, fibrous capsule around coated gel-filled silicone implants.

[Angioma of a finger: the usefulness of a graft from the hypothenar eminence for covering the defect]. / Angioma di un dito della mano: utilità dell'innesto dall'eminenza ipothenar per la copertura del difetto.

Skin grafting remains the simplest option when bone is not exposed in soft tissue losses of the digits of the hand. As opposed to traditional donor sites, a split-thickness skin graft from the hypothenar eminence provides specialized skin similar to the one to be replaced. The graft remains elastic and soft in follow-up, without hyperpigmentation, hyperkeratosis, fissuring and hypertrophic scarring at the margins. As well as in acute trauma situations, the use of split-thickness skin grafting from the hypothenar eminence can also be extended to resurfacing defects in elective hand surgery. As an example, we describe a case of an ulcerated capillary hemangioma on the dorsal surface of the fifth digit at the distal interphalangeal joint.

[Treatment of traumatic oto-hematoma with transfixed compression sutures]. / Sul trattamento dell'otoematoma traumatico con suture trasfisse di compressione.

The effective early treatment of oto-hematoma is important so as to prevent reaccumulation of fluid and the typical chronic "cauliflower ear" deformity. A simple method of treatment with the use of transfixed tie-through compression mattress sutures, incorporating bolster dressings on both surfaces of the ear, following drainage of the hematoma via a small skin incision, is presented. This allows an optimal immobilisation of the skin over underlying cartilage for 7-10 days, preventing the reaccumulation of fluid with subsequent thickening and fibrosis, frequent complications of the other current methods of treatment.

[Chemotherapy of intestinal carcinomas]. / Chemioterapia dei carcinomi intestinali.

It is not easy to weigh up therapeutic and toxic effects in the medical treatment of intestinal cancer. The number of drugs that have demonstrated certain activity in these forms is extremely limited, only 5 FU being definitely active and even this only in a small percentage of patients. 5 FU produces remission in some 20% of cases. It is highly probable that prophylactic treatment with 5 FU increases patient survival as reported by Regelson and other workers, but the resulting damage (hepatic, bone marrow, immunodepression, etc.) must also be assessed and the risk of a second neoplasia should not be forgotten. The personally used association of 5 FU and cyclophosphamide has proved active at least to the same extent as 5 FU alone, while toxic effects were not particularly important. Brilliant but unfortunately temporary results can be obtained by peritoneal PTC in peritoneal carcinomatosis. Good results with respect to the pain symptom have been obtained by associating 5 FU with radiotherapy in non-operable intestinal tumours.