New application of purse string suture in skin cancer surgery.

Closure of large wounds may require full-thickness skin grafts, but their use is burdened by donor tissue availability and morbidity; the use of the purse string technique is an elegant way to overcome this problem. The study highlights the gain in terms of graft donor site morbidity and oncological radicality. The study included a group of 47 patients who underwent surgical excision for skin cancer and whose wounds were covered using a purse string suture and a skin graft. Radius of the defect left was measured after the lesion's excision and after the purse string suture. Thereafter, the difference between the initial defect area and the area after purse string suture was calculated. Initial defects ranged from 3.85 to 61.5 cm2 . After skin graft, the purse string suture ranged between 2.2 and 40 cm2 (mean area = 14 cm2 ). Gained area before the graft measured from 1.3 to 21.5 cm2 (mean gained area = 7.1 cm2 ). Average reduction was 33%. The technique allows a reduction of the size of the area to be grafted and the skin graft donor area, thus increasing the possibility of the feasibility of full-thickness grafts. In addition, it allows an optimal observation both of the area of tumour excision and margins during follow-up controls.

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.

Effect of enzymatic debridement with two different collagenases versus mechanical debridement on chronic hard-to-heal wounds.

A chronic ulcer is usually defined as an injury that does not spontaneously evolve towards healing and does not progress through normal healing stages such as inflammation, proliferation and remodelling. This study was designed in order to compare two types of collagenases with mechanical debridement alone. It was thus possible to evaluate their differences in terms of pain and debridement efficacy. Patients were divided into three groups: 30 patients were daily dressed using an ointment based on collagenase produced by Vibrio alginolyticus (B group), 30 patients were daily dressed using an ointment based on a collagenase preparation derived from Clostridium histolyticum (N group) and 30 patients underwent classical mechanical debridement (M group). Complete wound healing over a period of 8 weeks occurred in 24 patients (27%) out of 90;10 patients belonging to the B group, 8 patients to the N group and 6 patients to the M group. This study was performed in order to highlight the differences between two commercially available collagenase-based ointments in comparison with mechanical debridement alone. At the final time point of week, the difference in the percentage of debridement was not statistically significant in all groups, but at 4 weeks, the debrided area in the B group was larger with respect to the N and M groups, suggesting a more rapid wound bed cleansing process. On the basis of our experience, collagenase derived from V. alginolyticus with hyaluronic acid showed chemical and physical properties that make it a product of great manageability and ensure the protection of peri-wound skin. Moreover, less pain was experienced by the patients.

Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: a perspective randomised study.

INTRODUCTION: Carpal tunnel decompression with division of the transverse carpal ligament has been a highly successful procedure for the treatment of carpal tunnel syndrome. The standard longitudinal incision technique, with a long curvilinear incision, has been the optimal treatment procedure for surgical decompression of the median nerve, for many surgeons. The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimal-access carpal tunnel release (MACTR) technique for the treatment of carpal tunnel syndrome (CTS), presenting our experience. MATERIALS AND METHODS: A total of 120 patients eligible for carpal tunnel decompression were recruited into the study. The patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by standard TOCTR, and 60 patients in group B, treated by MACTR. To evaluate patients' outcomes we used the Boston Carpal Tunnel (BCT) questionnaire; the formed scar was evaluated according to the Vancouver scale and short- and long-term complications. Statistical analysis was performed by the chi-squared test and analysis of variance (ANOVA); Excel was the program used. RESULTS: In our series, there was no complication related to the surgical intervention of any injury to nerve, artery or tendon structures. In each section of the BCT questionnaire, patients in group B had significantly better results than patients in group A at both 6 and 12 months' follow-up (p < 0.001). For the Vancouver scar scale, there was a significant difference between two groups' scores; group B patients had significant improvements compared with group A patients. CONCLUSIONS: In our perspective randomised study, MACTR showed statistically significant improvement compared to TOCTR. The patient tolerance is reasonably high and the procedure is compatible with the current minimal invasive trend in surgery.

The anteromedial thigh free flap anatomy: a clinical, anatomical, and cadaveric study.

BACKGROUND: Perforator flaps have become the choice of most reconstructive surgeons because they have decreased donor-site morbidity. Among these flaps, the free anteromedial thigh flap has not yet become a first-choice flap because of the inconstant anatomy of its pedicle. This study aimed to describe the anatomy from different perspectives to highlight common patterns and simplify the flap's application in clinical cases. METHODS: The study started in 2004 and took 9 years to complete. It was performed on 12 clinical anteromedial thigh flap cases, 48 clinical cases of anterolateral thigh flap in which the vascular anatomy of the anteromedial thigh flap was studied, and 48 cadaver dissections. RESULTS: In "type of perforators," the authors found an almost total consistency between clinical cases (group 1) and dissections in patients (group 2) (χ = 0.164 and p = 0.92), whereas the cadaver dissections (group 3) were minimally homogeneous (χ = 13.7 and p = 0.0082). Then, taking into account the parameter "origin of perforators," they noticed the same trend with a clear alignment between the first two groups (χ = 1.84 and p = 0.87) and a strong inhomogeneity in relation to the third group (χ = 19.8 and p = 0.03). CONCLUSIONS: Anatomical study of the anteromedial thigh flap pedicle showed a marked variability that makes preoperative planning difficult, and thus more stressful to realize. This evidence confirms that the flap can be used as a second choice or simultaneously with the anterolateral thigh flap. In addition, the authors strongly suggest a preoperative radiological study to minimize the possible anatomical variabilities during surgery.

Female pseudohermaphroditism: strategy and bias in a fast diagnosis. How tricky could be a diagnosis with a wrong anamnesis.

AIM: Congenital genitalia anomalies are a spectrum of malformation, difficult to classify because similar or identical phenotypes could have several different aetiology; therefore it's essential to assess an efficient diagnostic algorithm for a quick diagnosis and to develop an efficient therapeutic strategy. The aim of this study is to underline the importance of imaging in case of ambiguous genitalia due to its high sensitivity and specificity in detecting internal organs and urogenital anatomy. MATERIAL OF STUDY: We report a case of a young girl affected by a complex genitor-urinary malformation with an initial wrong anamnesis that led to a tricky diagnosis. RESULTS: Imaging techniques - especially Magnetic Resonance Imaging (MRI) - together with karyotype, hormones and physical investigations, offered complete and reliable informations for the best surgical treatment of our patient. CONCLUSION: Karyotype, hormones investigation, and radiological examinations are the main criteria considered in the diagnostic iter. Ultrasonography (US) is the primary modality for the detection of the presence or absence of gonads and müllerian derivatives, whereas Cystourethrography can define urethral and vaginal tract or the presence of fistulas. In our experience MRI, due to its multiplanar capability and superior soft tissue characterization, proved to be useful to provide detailed anatomic information.

The use of negative pressure therapy and hyaluronic acid for the management of post-traumatic lower limb injury.

Management of severe limb trauma continues to challenge surgeons. Suitable treatment should be individualised for each patient, taking into consideration not only the wound extremity but also the associated injuries, age and socioeconomic status of the patient with the goal to recover function and to improve patient quality of life. The aim of this report is to present a severe degloving multiplane lower limb injury case in which a conservative treatment of the wound was performed with negative pressure therapy and dermal substitute, avoiding amputation and restoring limb function.

Two-step surgery for a unique case of idiopathic female pseudohermaphroditism. Surgical treatment in an exceptional combined uro-genital malformation.

A 15 years-old patient was brought to our attention in June 2010 with a complex genito-urinary malformation: fusion of the labia majora and a partial union of labia minora, common urinary and vaginal meatus and clitoromegaly. The patient had a normal sexual feminine hormonal development. After diagnostic iter the patient underwent surgery twice. No signs of hormonal deficency was shown authorizing us to approach the disease as a congenital malformation due to an abnormality of intrauterine development. So surgical treatment was carried out, considering it as the gold standard for this type of malformations. It's considerable to emphasize that the association between clitoromegaly and fusion of the lower third of the urethra with the vagina has not been previously reported in the literature.

Lichen sclerosus in patients with squamous cell carcinoma. Our experience with partial penectomy and reconstruction with ventral fenestrated flap.

INTRODUCTION: The vast majority of penile malignant tumors are squamous cell carcinomas (SCCs). After histological diagnosis of penile carcinoma, when possible, more conservative procedures are performed, otherwise it is necessary to perform a total penectomy. MATERIAL AND METHODS: Ten patients, from 2006 to 2008, underwent to partial penectomy and reconstruction with ventral fenestrated flap technique; five of these patients had lichen sclerosus. All tumors were staged as T2N0M0, involving the corpus spongiosum and cavernosum. Patients were evaluated both the aesthetical and the sexual satisfaction, the first one by patient aesthetical self-assessment score, the second one by the International Index of Erectile Function (IIEF). Patients underwent follow-up for forty months. RESULTS: Of the ten patients, no one encountered severe complications. The average aesthetic satisfaction one month postoperatively was of 2 points, 40 months postoperatively it was of 3 points (scoring scale: 1= complete dissatisfaction, 5 = complete satisfaction). The average IIEF score in the preoperative period was 21.6 points, one month postoperatively it was 13 points, 40 months postoperatively it was 19.7 points (mild erectile dysfunction). DISCUSSION: The technique we presented, compared to other techniques, allows a reduction in operating time and is a one step technique without risk of non-engraftment. The ventral fenestrated flap technique did not result in metal stenosis in our ten patients series. CONCLUSIONS: The use of a ventral fenestrated flap in the closure of the defect due to partial penectomy has numerous advantages. Aesthetics is highly accepted by patients who are satisfied and report satisfactory sexual activity despite the reduction in penis length.

Morbidity of selective lymph node biopsy for melanoma: meta-analysis of complications.

BACKGROUND AND AIM: Intraoperative lymphatic mapping and selective lymph node biopsy is accepted worldwide as the standard procedure for staging regional lymph nodes of 1-4 mm thick melanomas, as well as for other neoplasms. Although it is often stated that selective lymph node biopsy is a minimally invasive procedure associated with few complications, few data exist concerning the morbidity associated with the procedure. The present analysis was performed to evaluate the morbidity associated with selective lymph node biopsy in a long-term follow-up. MATERIALS AND METHODS: The study provides a review of 437 selective lymph node biopsies on 269 patients, operated on between the 1994 and the 2009, for the lymph node biopsy of head and neck, groin, axilla, upper and lower limbs and nodal basins. Patients' history and follow-up were reviewed for 2 weeks after surgery, every 3 months for the first 2 years, every 4 months during the third year, and every 6 months subsequently, and postoperative morbidity was evaluated. RESULTS: After sentinel node biopsy, 14 patients developed one of the following complications: hematoma, 1 case (0.30%); lymphedema, 1 case (0.30%); seroma, 2 cases (0.61%); wound infection, 6 cases (1.83%); keloid scar, 2 cases (0.61%); and postoperative pain, 2 cases (0.61%). The total complication rate was 4.26%. CONCLUSIONS: Selective lymph node biopsy for melanoma, as for other tumors, in respect to radical lymphadenectomy, is not a complications-free procedure but is usually not severe.

Feasibility of conservative medical treatment for pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a chronic skin disease with an incidence of 3-10 per million, and it is often associated with underlying systemic disease. A case of PG of the left leg successfully treated with local debridement and advanced and compression dressings, without systemic treatment is reported. Progression and healing of the ulcer was incredibly rapid. The treatment of PG usually consists of systemic administration of corticosteroids. But wherever the administration of systemic immunosuppressive therapy is impractical, a topical treatment can be used. This type of treatment does not represent a mere palliative, but could be significant for healing, as in the case of our patient.

[Metatypical basal-cell carcinoma (MTC) or basosquamos carcinoma (BSC): surgical therapy]. / Carcinoma a cellule basali metatipiche (MTC) o carcinoma basosquamoso (BSC): terapia chirurgica.

AIM: Nonmelanoma skin cancer (NMSC) is the most common cancer in the world with an incidence 18-20 times greater than that of malignant melanoma. Basal cell carcinoma, which probably arises from immature pluripotential cells, is the most common malignant tumor of the skin in Caucasian. It occurs mostly on sun-exposed areas such as neck and face. MATERIAL OR STUDY: We performed a retrospective study of 327 consecutive patients, diagnosed for metatypical basal cell carcinoma. Tumors were analyzed and measured from the surgeon, excision margins were marked on the basis of palpable or visual alteration of the burden. The minimum surgical margin was equal to the short axis of the ellipse. Therapy was made according to guidelines. RESULTS: A relevant difference came out between two genders. 213 Males (65%) were affected in comparison with only 114 females (35%). Concerning areas affected, first is cervico-facial area with a prevalence of 220 cases (67.3%), second trunk 33 cases (10.1%), third other areas 29 cases (8.86%), fourth limbs 32 cases (9.80%), fifth scalp with 13 cases (4%). DISCUSSION AND CONCLUSIONS: Diagnosis is based on histological analysis. Histologically MTC is divided into two subtypes: intermediated and mixed. In the intermediate form transitional zones and tumor islets are found together, thus combining features of BCC and SCC In mixed subtype typical basal cells coexist with areas of conglomerated squamous cells, squamous pearls could be present.

Metatypical carcinoma. A review of 327 cases.

INTRODUCTION: Metatypical cell carcinoma is a quite rare malignancy (5% of all non melanoma skin cancers), with features of basal cell carcinoma and squamous cell carcinoma. It is described as coexistence of basal cell carcinoma and squamous cell carcinoma with no transition zone between them. MATERIALS AND METHODS: We performed a retrospective study of 327 consecutive patients, diagnosed for metatypical carcinoma. Statistical analysis was made to determinate most affected areas, gender prevalence, average age, presence of ulceration and infiltration, peripheral clearance rate. RESULTS: A relevant difference came out between two genders. Chi-square test emphasized a relation between females and the presence of carcinoma on the scalp. In addition a strong correlation between mixed subtype and ulceration was evident. A strong relation between intermediate subtype and positive surgical margin was found; this data could identify a more aggressive behavior of intermediate type. DISCUSSION: Differently from melanoma that usually arises on sun exposed areas, no relation was found between sun exposion and this tumor. This characteristic stresses on the importance of other risks factor apart from sun exposition. CONCLUSIONS: We identify some correlation between our data that cannot be explained with previous interpretation of sun exposition.

ABCB5 in peripheral blood of a patient affected by multiple primary malignancies.

BACKGROUND: Multiple primary neoplasm malignancies syndrome (MPMN), is the presence of two or more abnormal growths of tissue, occurring simultaneously. Although the number of second malignancies is increasing, due to several factors, the presence of triple or quadruple malignancies is still very rare. PATIENT AND METHODS: We report a case of a 78-year-old man, with six primaries: a prostatic adenocarcinoma, breast cancer, two melanoma, a basal cell carcinoma, and a lymphoma in a four years period. RESULTS: The onset of MPMN is probably caused by a mutation of DNA repair genes, probably the TP53 gene. Common features of this syndrome are early rise and low tendency to metastatize. We reviewed the markers of staminality for various tumors: RNA expression of ALDH1, CD 133, and ABCB 5, extracted from the sentinel lymph node (SLN) and from the peripheral blood of the patient, was verified. CONCLUSION: People with multiple tumors represent a segment of the cancer-survivor population, which is continuously increasing (10%). Several genetic mutation can be involved in this kind of population. Our patient was positive for the expression of ABCB5, a marker for staminality of melanoma, in periphal blood.

Basal cell carcinoma: 10 years of experience.

Introduction. Basal cell carcinoma (BCC) is a locally invasive malignant epidermal tumour. Incidence is increasing by 10% per year; incidence of metastases is minimal, but relapses are frequent (40%-50%). The complete excision of the BCC allows reduction of relapse. Materials and Methods. The study cohort consists of 1123 patients underwent surgery for basal cell carcinoma between 1999 and 2009. Patient and tumor characteristics recorded are: age; gender; localization (head and neck, trunk, and upper and lower extremities), tumor size, excisional margins adopted, and relapses. Results. The study considered a group of 1123 patients affected by basal cell carcinoma. Relapses occurred in 30 cases (2,67%), 27 out of 30 relapses occurred in noble areas, where peripheral margin was <3 mm. Incompletely excised basal cell carcinoma occurred in 21 patients (1,87%) and were treated with an additional excision. Discussion. Although guidelines indicate 3 mm peripheral margin of excision in BCC <2 cm, in our experience, a margin of less than 5 mm results in a high risk of incomplete excisions.

A study of intraabdominal pressure modification in "component separation" technique for repair of incisional hernia.

INTRODUCTION: Incisional hernias can be treated with laparoscopic and laparotomic surgery. Laparoscopic surgery can be made without the use of mesh when performing component separation technique. This technique allows to limit the adverse effects to foreign body and promotes a tension-free closure. We studied intravescical pressure changes during intervention in order to quantify intrabdominal pressure. MATERIAL AND METHODS: A prospective, non-controlled study (cohort study), was made on thirty patients, treated to repair incisional hernia. Standard panniculectomies and component separation technique were performed in all patients. A standard Foley catheter was inserted in to the bladder in order to measure pressure modification in the peri-/postoperative phases. Statistical significance of modifications of pressure values was evaluated with the Wilcoxon's sum rank test. RESULTS: Bladder pressure increased after hernia repair and skin closure and decreased in the first day after surgery, but without returning to the original values, and these modifications were statistically significant. DISCUSSION: We study intravescical pressure changes as an indirect measurement of intrabdominal pressure. Intrabdominal pressure cut-off for the rise of complications is 20 mmHg. This technique allows to maintain pressure under dangerous limits and to limits complications.

A large vascular leiomyoma or an infected sebaceous cyst of the chest? A case report.

INTRODUCTION: Vascular leiomyoma is a rare tumour of smooth muscle origin. It has been reported in many anatomical sites, but it usually affects limbs. It's recurrence rate is slow but it's quite difficult to make diagnosis. CASE REPORT: The study describes the case of a 53-year-old man, with a subcutaneous, large vascular leiomyoma of the right clavicular region. The patient had a painful, slow-growing mass, measuring more than 20 mm. The mass had a relatively homogeneous, hypoechoic-echo texture, with a small amount of posterior acoustic enhancement. No diagnosis was made and the patient underwent surgery for a suspected leyomioma. After surgery a hard, round-shaped tumor, measuring approximately 43 x 32 mm of diameter was found with histological features of leyomioma. DISCUSSION: The case has an unusual clinical presentation, for the uncommon localization and size of the mass. US imaging and histopathologic features are reported. The rarity of vascular leiomyoma makes diagnosis difficult and frequently delayed. Differential diagnosis includes infected sebaceous cysts, glomus tumors, hemangiomas, angiolipomas, ganglions, and traumatic neuromas. CONCLUSIONS: This report highlights that leiomyoma, even of large dimension, must be included in the differential diagnosis of painful, subcutaneous masses.