Treatment of a Case of Toe Hair-Thread Tourniquet Syndrome With Hirasè Technique.

ABSTRACT: Hair-thread tourniquet syndrome (HTTS) is an uncommon condition that affects mostly babies, usually a few months old. It happens when a strand of hair or cloth fiber encircles an appendage causing a condition of total or subtotal ischemia (West J Med 1976;125:335-336). This condition has been described several times in the recent literature. Appendages involved include toes, fingers, genitalia, uvula, and neck (N Engl J Med 1965;273:866-867). The mechanism of injury usually involves the fiber cutting the skin deeply through soft tissues, veins, and arteries. As HTTS occurs in small babies and hidden parts of the body, sometimes this event can be very difficult to detect and irritability may be the only symptom. The treatment consists of releasing the circumferential constriction and restoring the arteriovenous flow also with microsurgical techniques if vessel interruption is present. Unfortunately, the fiber or the thread often penetrates so deep that, once an HTTS is recognized, it may be very challenging to identify and trim. The authors present a case of HTTS of the second toe of the right foot in a 2-month-old baby treated with surgical release and Hirasè technique. After the thread was successfully cut and removed, the forefoot was covered with aluminum foil, and a bag with ice was immediately put all around. After 3 days, we observed a complete survival of the toe without any sign of necrosis. Later control at 6 months showed complete restitutio ad integrum of the affected digit with a normal perfusion and absence of any onychopathy. Hirasè technique represents a simple, safe, and low-cost option of treatment for HTTS.

FRAIL scale as a predictor of complications and mortality in older patients undergoing reconstructive surgery for non-melanoma skin cancer.

The aim of the present study was to determine the association between preoperative frailty and the onset of surgical complications in patients diagnosed with massive non-melanoma skin cancer subjected to plastic and reconstructive surgery. A retrospective analysis was performed on a cohort of 587 patients with non-melanoma skin cancer, selected on the basis of specific inclusion criteria, who were subjected to plastic and reconstructive surgery between 2005 and 2014. Frailty was scored using the FRAIL index, whereas postoperative complications were classified according to Clavien-Dindo criteria. By binary logistic regression, the odds and probabilities of complications were calculated as a function of increasing values of the FRAIL index. Two different logistic models were created, comparing absent/mild (Clavien grades 1st and 2nd) vs. moderate/severe complications or mortality (Clavien grades 3rd-5th; model A), or absent/mild/moderate complications (Clavien grades 1st-3rd) vs. severe complications or mortality (Clavien grades 4th and 5th; model B). The FRAIL index was an accurate predictor of surgical complications or mortality, with significant odds ratios and goodness of fit. In model A, FRAIL scores 4 and 5 were the most critical predictors of moderate/severe complications or mortality (37 and 94% probability, 0.6 and 17.3 odds, respectively), compared to score 3 (2% probability, 0.02 odds) or lower. In model B, FRAIL score 5 was the most critical predictor of severe complications or mortality, as it was associated with a 74.6% probability and 2.93 odds for these events. In conclusion, increasing FRAIL scores were associated with worsening surgical outcomes for patients with non-melanoma skin cancer undergoing plastic/reconstructive surgery. A low rate of surgical complications was observed in pre-frail and frail patients up to FRAIL score 3.

Use of human fat grafting in the prevention of perineural adherence: Experimental study in athymic mouse.

Perineural adherences represent a problem after surgery involving peripheral neural system. Fat-grafting with adipose derived stem cells (ASCs) with their pro-regenerative characteristics can be important to prevent the neural damage or to facilitate the neural regeneration. Our idea was to use the fat-grafting as an anti-adherence device and test its efficacy on a postsurgical scar animal model and comparing to an antiadhesive gel. 32 athymic mice were operated under magnification, we exposed both sciatic nerves. We randomly divided all sciatic nerves into four experimental groups: burning (1), burning + carboxy-methylcellulose and poly- ethylene oxide (CMC-PEO) (2) + human adipose fat tissue (3), control group (4). Bio-mechanical evaluation was performed to measure the peak force required to pull out the nerve from the muscular bed. RESULTS: in the CMC-PEO group the peak pull out force was 0.37 Newton. In the fat grafted group we registered a peak pull out force of 0.35 N (t Student 0.913). In burning group the force necessary to tear the nerve apart was markedly superior (0.46 N). In control group, we reported the minimal strength (0.31 N) to slide the nerve from the tissue. Histologically, in the group treated with fat-grating, a thinner scar layer was highlighted. Considering the results of this study we can support the efficacy in animal experimental model of fat graft as an anti-adherence device in peripheral nerve surgery.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection.

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments.

Free gracilis flap for chest wall reconstruction in male patient with Poland syndrome after implant failure.

Poland's syndrome (PS) is a congenital monolateral deformity that may involve breast, chest wall, and upper limb with different degrees of clinical expressions. In some cases, the problem is mainly cosmetic, and the reconstruction should be performed to achieve minimal scarring and donor site morbidity. The authors describe a case report of a male patient with PS who developed a severe capsular contraction after 25 years implant reconstruction, who was treated after explantation using free gracilis flap (FGF). In this patient, only the pectoralis major muscle was missing. An FGF was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, the patient had a clearly improved appearance of the chest wall, and the pain syndrome was solved. In this case report, we demonstrate our experience with the use of an FGF for chest wall reconstruction in male patients with PS after prosthesis explantation.

Human adipose-derived stem cells promote vascularization of collagen-based scaffolds transplanted into nude mice.

AIM: After in vivo implantation of cell-loaded devices, only the cells close to the capillaries can obtain nutrients to maintain their functions. It is known that factors secreted by stem cells, rather than stem cells themselves, are fundamental to guarantee new vascularization in the area of implant. MATERIALS & METHODS: To investigate this possibility, we have grafted mice with Bilayer and Flowable Integra(®) scaffolds, loaded or not with human adipose-derived stem cells. RESULTS: Our results support the therapeutic potential of human adipose-derived stem cells to induce new vascular networks of engineered organs and tissues. CONCLUSION: This finding suggests that our approach can help to form new vascular networks that allow sufficient vascularization of engineered organs and tissues in cases of difficult wound healing due to ischemic conditions.

Efficacy of anti-adhesion gel of carboxymethylcellulose with polyethylene oxide on peripheral nerve: Experimental results on a mouse model.

INTRODUCTION: Perineural scar formation is responsible for pain and loss of function after surgical procedures. Neurolysis and application of anti-adhesion gels are required to restore a gliding surface. We tested a carboxymethylcellulose (CMC) and polyethylene oxide (PEO) gel on mouse sciatic nerve to describe its safety and efficacy. METHODS: Adult mice underwent a surgical procedure in which we burned the muscular bed of the sciatic nerve bilaterally (Burned group) and applied anti-adhesion gel to 1 of the nerves (Burned+gel group). After 3 weeks, we studied scar tissue by biomechanical and histological evaluation. RESULTS: Both histological and biomechanical analysis showed that the gel reduced perineural scarring. The difference between the Burned and Burned+gel groups was statistically significant. CONCLUSIONS: CMC-PEO gel can reduce perineural scar tissue. In histological section, scar tissue was present in both groups, but in the Burned+gel group a gliding surface was identified between scar and nerve.

Acellular dermal matrices and radiotherapy in breast reconstruction: a systematic review and meta-analysis of the literature.

The increasing use of commercially available acellular dermis matrices for postmastectomy breast reconstruction seems to have simplified the surgical procedure and enhanced the outcome. These materials, generally considered to be highly safe or with only minor contraindications due to the necessary manipulation in preparatory phases, allow an easier one-phase surgical procedure, in comparison with autologous flaps, offering a high patient satisfaction. Unfortunately, the claim for a higher rate of complications associated with irradiation at the implant site, especially when the radiation therapy was given before the reconstructive surgery, suggested a careful behaviour when this technique is preferred. However, this hypothesis was never submitted to a crucial test, and data supporting it are often discordant or incomplete. To provide a comprehensive analysis of the field, we searched and systematically reviewed papers published after year 2005 and registered clinical trials. On the basis of a meta-analysis of data, we conclude that the negative effect of the radiotherapy on the breast reconstruction seems to be evident even in the case of acellular dermis matrices aided surgery. However, more trials are needed to make solid conclusions and clarify the poor comprehension of all the factors negatively influencing outcome.

A simple and reliable method to perform biomechanical evaluation of postoperative nerve adhesions.

BACKGROUND: Perineural fibrotic adhesions are among the major complications of peripheral nerve surgery. While different experimental models have been used for the pre-clinical testing of anti-adherential strategies, the methods used so far to induce scar tissue appear to be poorly standardized and reproducible. NEW METHOD: Thirty adult mice were used. Two methods were tested: the first one is based on burning the perineural muscular bed with a diathermocoagulator, while the second is based on direct scratching of the nerve surface with a cotton swab. After 3 weeks, the fibrotic reaction was assessed by measuring the peak pull out force of the nerve from muscular bed by means of a new tool specifically devised for biomechanical assessment of scar tissue formation. Moreover, histological analysis with specific collagen stain was also carried out. RESULTS: Both methods produced fibrotic reaction. Statistical analysis of biomechanical data showed a significant difference between burning and scratching group compared to the control sham operated group. No significant differences were detected between burning and scratching group. Histological analysis showed the presence of perineural scar tissue in both groups, though with a different distribution pattern. COMPARISON WITH OTHER METHODS: This protocol is easier to perform. The tool used for biomechanical evaluation is reliable and cheap. CONCLUSIONS: Both methods for perineural scar formation are effective and simple. They represent reproducible models for the study of the anti-adherential strategies. Yet, biomechanical testing with the device that we have developed proved to be a reliable and simple method for the quantitative assessment of the degree of perineural adhesion formation.

Reconstructive management of degloving trauma of male external genitalia using dermal regeneration template: a case report.

Traumatic injuries of male external genitalia are rare and not usually life threatening; however, they can have psychological repercussions. The reconstructive management of these lesions is challenging and articulated. We report the case of a 38-year-old farmer suffering from a degloving wound on the external genitalia. The first reconstructive step used to treat the wound was the incorporation of a dermal regeneration template (Integra(®)) and accordingly partial-thickness skin grafts and local flaps. The follow-up 16 months after the first treatment was satisfying; sexual function had been restored.

A Novel Surgical Technique to Correct Intrareolar Polythelia.

Polythelia is a rare congenital malformation that occurs in 1-2% of the population. Intra-areolar polythelia is the presence of one or more supernumerary nipples located within the areola. This is extremely rare. This article presents 3 cases of intra-areolar polythelia treated at our Department. These cases did not present other associated malformation. Surgical correction was performed for psychological and cosmetic reasons using advancement flaps. The aesthetic and functional results were satisfactory.

Evaluation of lymphangiogenesis in acellular dermal matrix.

INTRODUCTION: Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA(®). On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects. MATERIALS AND METHODS: Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA(®) implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis. RESULTS: We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels' lumen in this group. CONCLUSION: This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.

Squamous cell carcinoma and ledderhose disease: a case report.

Ledderhose disease is disorder of the plantar aponeurosis. This disease is not so common and can be tackled with a surgical or conservative approach. A case of a 73-year-old man came to our attention who had a 26-year history of painless bilateral plantar nodules coalescing into an indurated mass. An ulcerative nodule had been noted in the last 16 months on the right foot, in the absence of trauma, not responsive to conservative treatment, so we decided to perform a biopsy. The histopatologic examination showed squamous cell carcinoma, with warty, well-differentiated, low-grade malignancy. Surgical treatment was suggested, so, in pneumoischemia, we made a surgical incision including the skin lesion. Then we proceeded to sculpture the anterolateral thigh fasciacutaneous flap to obtain adequate soft tissue coverage. The tumor was completely removed. Current reconstructive possibilities comprise a good anatomofunctional recovery even in the case of large demolition requests for the therapy of advanced cases of the disease described in this article. Correlation between Ledderhose disease and the formation of malignant tumors has not been made as yet, but perhaps an element that could unite these pathologies can be researched in the lively cell proliferation that characterizes both. It would be interesting to analyze the biological substrate, as well as the systemic and local levels, in patients where both diseases are manifested.

Massive de-gloving thigh injury treated by vacuum therapy, dermal regeneration matrix and lipografting.

Frequently lower limb injuries are caused by road and work accidents. The young age of those affected coupled with the anatomical and functional peculiarities of this part of the body with regards to social life during adolescence make the treatment of the leg wound complex and challenging. We present two cases of young girls, victims of serious road accidents who were treated initially with frequent wound washings, vacuum therapy to stimulate granulation tissue, then dermal regeneration matrix (INTEGRA®) and split-thickness skin grafts. After one year, both patients treated with lipofilling have shown improved cosmetic results allowing a new social life.

A case of facial lipoatrophy secondary to lupus profundus managed with lipofilling technique.

Facial lipoatrophy is one of the most difficult complication in the patients with lupus profundus. In this paper, we present a case of a 55-year-old woman affected by lupus profundus, with a grade V lipoatrophy, treated with lipofilling technique. No complications were observed and results at 12 months were stable, natural, and symmetric.