An Alternative Treatment Strategy for Complicated Chronic Wounds: Negative Pressure Therapy over Mesh Skin Graft.

Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p < 0.0009, p < 0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take.

Retention of polyurethane foam fragments during VAC therapy: a complication to be considered.

Vacuum-assisted closure (VAC) therapy is a closed-loop, non-invasive active system, characterised by a controlled and localised negative pressure applied on porous polyurethane absorbent foams. It promotes healing of acute and chronic wounds. Therapeutic effects of VAC therapy have been proved and demonstrated; however, this method can have some disadvantages. Even if it is a quite versatile device, only qualified medical/paramedical personnel should use it in order to avoid possible complications that can occur after an improper application. In this report, 11 cases of foam-fragment retention within the wound are presented. This rare complication did not promote healing, but further hindered it. On the basis of our experience, it is mandatory to define the indications, benefits and limitations of VAC therapy.

The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study.

Various vaginoplasty methods in male-to-female transsexuals have been described, but none is ideal. The use of cultured autologous oral epithelium to cover the neovagina walls is presented. Six patients were operated on. Complications encountered were one case of low-located rectovaginal fistula that was treated conservatively; one case of partial glans necrosis resulting in a scarred but sensitive clitoris; one case of large labia majora requiring reduction; and one case of short vagina requiring surgical revision with autologous cultured oral cells that was successful. All patients had adequate vagina, experienced sexual intercourse, and were satisfied with results. Autologous cultured oral epithelium transplantation is feasible, safe, and advantageous. Satisfactory neovaginas were provided; the procedure is relatively easy to perform and provides a thin, mucosa-lined neovagina with a sufficient amount of secretion.

Transverse upper gracilis flap with implant in postmastectomy breast reconstruction: a case report.

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin-sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.

Treatment of pectoralis major flap myospasms with botulinum toxin type A in head and neck reconstruction.

BACKGROUND: Treatment options for muscle spasm complications of the pectoralis major (PM) flap in head and neck reconstruction have hardly been investigated. The authors report their experience using botulinum toxin (BTX-A) injections as a treatment of PM flap myospasm complications in head and neck reconstruction. METHODS: From January 2005 to May 2009, 83 patients underwent PM flap reconstruction. Eleven of them reported muscle twitching as a post-operative complication and are therefore included in this study. As all 11 patients refused a second surgery, they were offered BTX-A injections. This group of patients was followed up at regular intervals with clinical examinations, digital photography, range of motion (ROM) of the neck in different vectors, and neck disability system (NDS) questionnaires. RESULTS: After the first BTX-A infiltration, muscle twitching decreased, the ROM values increased and, according to the NDS, patients' discomfort progressively decreased. Only two of the 11 patients required two additional BTX-A sessions. CONCLUSION: BTX-A infiltration is an effective non-invasive procedure that significantly reduces the PM muscular contraction in head and neck reconstruction.

Implant infection after augmentation mammaplasty: a review of the literature and report of a multidrug-resistant Candida albicans infection.

BACKGROUND: Implant breast augmentation is one of the most frequently performed surgical procedures, and fungal infection still is considered exceptional. This report presents a case of bilateral breast implant infection by multidrug-resistant Candida albicans treated with a targeted antifungal therapy. METHODS: A young woman presented with breast pain and asymmetry as well as implant superficialization in the left breast 3 years after bilateral tuberous breast correction with implant insertion. She did not report any trauma to the chest wall or recent systemic infections. The breast was evaluated through mammary compliance analysis and magnetic resonance imaging (MRI). RESULTS: At surgery, both implants showed capsule contracture and were surrounded by a gelatinous yellow-brown and turbid fluid, which was sent for microbial and fungal analysis. A bilateral capsulectomy was performed. After copious irrigation of the subglandular pockets, submuscular pockets were created, and implants were substituted. Culture swabs tested positive for C. albicans and showed drug resistance to amphotericin B, fluconazole, itraconazole, and voriconazole on the fungal antibiogram. Targeted antifungal therapy with caspofungin was administrated in association with oral antibiotic therapy. Follow-up assessment at 1, 3, 6, 12, and 24 months did not show any infection or contracture relapse. CONCLUSIONS: This is the first report in the literature on a breast implant infection by a multidrug-resistant C. albicans. The study focused on the association between fungal contamination and capsular contracture and investigated the importance of a fungal antibiogram in cases of suspected prosthesis infection for performance of a targeted antifungal treatment.

A clinical study of late seroma in breast implantation surgery.

BACKGROUND: The use of mammary implants may lead to a variety of early and delayed complications. The most common delayed complications are capsular contracture and implant failure. Late seroma has seldom been reported. In a long-term prospective observational study, cases of late seroma were assessed and recorded. METHODS: Between March 2005 and November 2009, suspected cases of late seroma in patients who had undergone breast augmentation or reconstruction with textured implants were evaluated clinically and with instrumental analyses. An ultrasound-guided needle aspiration of the fluid was performed. RESULTS: In this study, 13 cases of late seroma (8 augmentations and 5 reconstructions) were observed. The overall incidence of this complication was 1.68%. Chemical analyses confirmed the diagnosis of seroma, which recurred in all the patients within days of evacuation. For 12 patients, a reoperation was performed, during which the implant was removed, a total capsulectomy was performed, and in cases of subglandular breast augmentation, the implant pocket was changed to a submuscular placement before a new prosthesis was inserted. One patient underwent a second ultrasound-guided needle aspiration. No seroma recurrence was observed in any of the patients during the follow-up period. CONCLUSION: In case of unexpected breast enlargement after prosthesis implantation, the physician should first rule out infection, then investigate possible friction irritation from either a fold in the device or rubbing of a textured implant. According to the authors' experience and another report, this complication occurs in 1% to 2% of cases. The inclusion of this complication in the informed consent form should be considered. Long-term studies designed to investigate the underlying causes of late seroma are warranted for the prevention and treatment of this complication.

Botulinum toxin for glabellar lines: a review of the efficacy and safety of currently available products.

Facial rhytides represent a widespread aesthetic concern. In particular, glabellar lines are perceived as a sign of aging and may give an erroneous impression of negative emotions. The onset of glabellar lines is closely related to the movements of the underlying muscles. Botulinum toxins inhibit the release of acetylcholine into the synaptic cleft and therefore result in temporary muscle paralysis. The observation that botulinum toxin (BTX) smoothed facial lines when used therapeutically led researchers to study the toxin effect on glabellar lines. Nowadays, the use of BTX to smooth glabellar frown lines represents the leading procedure in aesthetic facial treatments and an increasing number of BTX formulations are becoming available. This article provides a comparative evaluation of currently available BTX options for the treatment of glabellar lines. Toxins have been divided into three groups, based on whether they have obtained approval for cosmetic use (approved treatments) or not (off-label treatments), or whether they are still under investigation (experimental treatments). We examine the basic similarities and differences between available botulinum toxins, and summarize the pharmacokinetics and dosing. All approved treatments consist of BTX type A (BTX-A) and differ in their molecular weight, as some formulations are made of a BTX-A complex of 900 kDa while the latest option on the market is a 150 kDa BTX-A that is free from complexing proteins. As for the dosage, the important aspect that emerges from this comparison is that even within a given serotype, such as BTX-A, formulations are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes. There is a substantial body of published evidence on the use of these approved treatments for facial enhancement, proving efficacy and safety. We investigate the methods of evaluation used for each toxin and review the safety and efficacy data reported in the literature. Minor adverse effects, such as headache, blepharoptosis, and injection-site reactions, are relatively frequent but transient, whilst major adverse effects are rare. Some botulinum toxins, i.e. BTX type B, that are approved for therapeutic applications are used off-label for cosmetic indications, thus without the approval of the health regulatory committees and without sufficient published evidence on safety and efficacy. As for experimental treatments, a number of BTX products are currently in development or have been recently launched for aesthetic applications. These products have been specifically designed to overcome some of the limitations present in the older generation of products. However, some of these toxins may be easily purchased via the Internet, without having any license or approval for cosmetic or therapeutic indications; these products must be considered unsafe and are potentially a severe health risk for patients.

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.

Long-term results of a versatile technique for umbilicoplasty in abdominoplasty.

BACKGROUND: Umbilical repositioning is a main step in performing abdominoplasty. The surgical aims are minimal visible scars and a natural-appearing result. Reported techniques do not completely satisfy the aesthetic targets for all types of patients. A previous study reported a versatile technique for umbilicoplasty based on an elliptical vertical incision of the umbilical skin and a double opposing "Y" incision on the abdominal flap to create a new umbilicus. This report describes the long-term results with this technique. METHODS: A total of 111 abdominoplasties were performed. Patient satisfaction and postoperative results were evaluated over a 5-year follow-up period. A modified 5-ml syringe was used to assess the depth and volume of the umbilical stalk. Depth value variations were statistically compared using the Wilcoxon test. RESULTS: For all the patients, a three-dimensional umbilicus with an adequate depression was created. In four cases, deepithelialization of the umbilical skin occurred. After 1 postoperative year, no significant changes in umbilical shape, dimension, depth, or appearance were observed. After 5 years, no significant changes in shape or appearance were observed. The cicatricial umbilical stenosis occurrence was 4.5%. A small significant decrease in umbilical depth was noted. Overall, the results remained satisfying at this writing. CONCLUSIONS: The reported technique is easy to learn, simple to perform, and stable over time. It gives a natural depth appearance, ensures optimal position, pulls scars deeply, and allows achievement of different shapes according to the patient's habitus.

The double opposing "Y" technique for umbilical reconstruction after omphalectomy.

BACKGROUND: Abdominal surgical procedures, such as ventral hernia repair, may require the removal of the umbilicus, which gives an unnatural appearance to the abdomen. This situation can be corrected by umbilical reconstruction during the same operative time or at a later stage. In previous studies, we reported a versatile technique for umbilicoplasty based on a double opposing "Y" incision on the abdominal flap to create a new umbilicus. We now report the use of this technique for umbilical reconstruction in patients who underwent previous or concurrent omphalectomy. METHODS: A prospective open-label study was performed on 10 patients undergoing the double opposed "Y" umbilicoplasty after omphalectomy. Postoperative patients' satisfaction and results were evaluated during the follow-up of minimum 1 year. A modified 5 ml syringe was used to assess depth and volume of umbilical stalk. Depth value variations from one month to one year after surgery were statistically compared using the Wilcoxon test. RESULTS: Complete healing of the new umbilicus was achieved in 14-21 days in nine cases. In one case, partial dehiscence of the wound occurred and complete healing was achieved in 4 weeks. Follow-up time ranged from 1 to 4 years. In all patients, a three-dimensional umbilicus with satisfactory depression was created. During follow-up, no significant changes in shape, dimension and appearance were observed. All patients were pleased with the results. No cicatricial umbilical stenosis occurred. CONCLUSIONS: The double opposing "Y" technique creates a new natural umbilical scar; this technique can be easily performed for umbilical reconstruction after omphalectomy.

Umbilical endometriosis, our experience.

BACKGROUND: Endometriosis is the presence of functioning endometrial tissue outside the uterine cavity. Umbilical endometriosis has been reported in more than one hundred cases and the umbilicus represents the location of 0.5-1% of ectopical endometrioses. A correct differential diagnosis can be difficult and the use of epiluminescence and MRI is suggested for the accuracy of preoperative diagnosis. PATIENTS AND METHODS: We report our experience in preoperative differential diagnosis and treatment of four cases of umbilical endometriosis. An accurate anamnesis and clinical examination together with the use of 13 MHz probe ultrasonography with echocolor duplex scan led us to an accurate pre-operative diagnosis of umbilical endometriosis. The surgical approach to umbilical endometriosis represented an important step in achieving a satisfying result. RESULTS AND CONCLUSION: In all treated cases, a hemi-circumferential incision in the inner aspect of the umbilical opening was performed allowing adequate access to the lesion and umbilical repositioning. At the follow-up visit (from 6 to 24 months after surgery), no symptoms or signs of recurrence were evidenced. A natural-looking umbilicus was observed in all cases with minimal visible scars.

Conservative management of local Mycobacterium chelonae infection after combined liposuction and lipofilling.

A case of Mycobacterium chelonae infection in the buttock after combined liposuction and lipoinjection is presented. The real possibility of contamination from operating room equipment was the potential etiologic factor of this infection. The clinical presentation of the disease was typical. The difficulty confirming the diagnosis was solved by specific culturing techniques. Successful treatment with limited debridement and irrigation combined with prolonged specific antibiotic therapy effected a long-term cure.