Aesthetic and Functional Results after Single- and Two-Stage Resection and Reconstruction of Penile Paraffinomas - Experience from Two Tertiary Centers and a Surgical Management Algorithm.

The treatment of choice of penile paraffinoma (PP) is surgical resection. Penile soft tissue coverage in a combined Urology/Plastic Surgery procedure, is often needed. OBJECTIVE: To describe the surgical techniques, aesthetics and functional outcomes, and to provide a practical algorithm for the surgical management of symptomatic PP. METHODS: We retrospectively recruited PP patients treated with surgical resection, from 2004 to 2020, in the Reina Sofia Hospital of Murcia (Spain) and Sourasky Medical Center (Israel). Procedural and postoperative erectile function, according to the short version of the International Index of Erectile Function (IIEF-5) data were collected. RESULTS: Eight patients underwent surgery. The mean age was 30 years. The mean time between substance injection and surgery was 6 years. The most frequently injected material was liquid paraffin (50%), followed by Vaseline. Extensive skin involvement was present in all patients with liquid paraffin, requiring 2-stage surgery or skin graft. PP surgical treatment was successfully achieved in an Urology/Plastic Surgery joined effort. Postoperative erectile function was preserved in all cases. CONCLUSION: PP can pose a surgical challenge. A combined surgical approach with urology and plastics allows for functional and aesthetic preservation. The extent of PP and the viability of shaft skin preservation should guide surgical approach.

Oncoplastic reduction using the vertical scar superior-medial pedicle pattern technique for immediate partial breast reconstruction.

BACKGROUND: Oncoplastic breast reduction in women with medium to large breasts has reportedly benefitted them both oncologically and cosmetically. We present our experience with an oncoplastic breast reduction technique using a vertical scar superior-medial pedicle pattern for immediate partial breast reconstruction. METHODS: All patients with breast tumours who underwent vertical scar superior-medial pedicle reduction pattern oncoplastic surgery at our centre between September 2006 and June 2010 were retrospectively studied. Follow-up continued from 12 months to 6 years. RESULTS: Twenty women (age 28-72 yr) were enrolled: 16 with invasive carcinoma and 4 with benign tumours. They all had tumour-free surgical margins, and no further oncological operations were required. The patients expressed a high degree of satisfaction from the surgical outcome in terms of improved quality of life and a good cosmetic result. CONCLUSION: The vertical scar superior-medial pedicle reduction pattern is a versatile oncoplastic technique that allows breast tissue rearrangement for various tumour locations. It is oncologically beneficial and is associated with high patient satisfaction.

CONTEXTE: Chez des femmes qui avaient une poitrine de moyenne à volumineuse, la réduction mammaire oncoplastique aurait exercé des bienfaits, tant au plan oncologique que cosmétique. Nous présentons notre expérience d'une technique de réduction mammaire oncoplastique à cicatrice verticale et pédicule supéromédian pour une reconstruction mammaire partielle immédiate. MÉTHODES: Tous les cas de tumeurs mammaires soumis à la réduction à cicatrice verticale et pédicule supéromédian en chirurgie oncoplastique dans notre centre entre septembre 2006 et juin 2010 ont été passés en revue rétrospectivement. Le suivi s'est échelonné sur 1 à 6 ans. RÉSULTATS: Vingt femmes (âgées de 28 à 72 ans) ont été inscrites : 16 étaient atteintes d'un cancer envahissant et 4 de tumeurs bénignes. Elles présentaient toutes des marges chirurgicales libres de tumeur et aucune autre intervention oncologique n'a été nécessaire. Les patientes ont exprimé un degré élevé de satisfaction à l'endroit des résultats de la chirurgie pour ce qui est de l'amélioration de leur qualité de vie et de l'effet cosmétique positif. CONCLUSION: La technique de réduction à cicatrice verticale et pédicule supéromédian est une technique oncoplastique flexible qui permet un réarrangement des tissus mammaires en fonction de la localisation des tumeurs. Au plan oncologique, elle est bénéfique et associée à un degré élevé de satisfaction chez les patientes.

Simultaneous contralateral breast adjustment in unilateral deep inferior epigastric perforator breast reconstruction.

BACKGROUND: Breast symmetry is a key factor in deep inferior epigastric perforator (DIEP) flap breast reconstruction, which necessitates in many cases contralateral breast adjustment, traditionally done at a second stage. We present our experience with simultaneous contralateral breast adjustment in unilateral DIEP breast reconstruction. METHODS: We retrospectively reviewed all consecutive unilateral DIEP breast reconstructions done in our institution. The patients were divided into three groups according to contralateral breast surgery performed: simultaneous adjustment, late adjustment, and no contralateral breast adjustment surgery. The groups were compared by aesthetic outcome and patient satisfaction using the BREAST-Q questionnaire. RESULTS: A total of 77 unilateral breast reconstructions were performed using the DIEP flap. Fifty-one eligible patients agreed to respond to the questionnaire by telephone and were enrolled in the study; 33 underwent simultaneous contralateral breast adjustment, eight underwent late adjustment procedure, and 10 had no contralateral surgery performed. Aesthetic outcome and patient satisfaction was comparable in the simultaneous and late adjustment groups, but was reduced during the latent period. CONCLUSION: Simultaneous contralateral breast adjustment in unilateral DIEP breast reconstruction is a safe and a worthwhile procedure that should be offered to the patient when appropriate.

Use of the oncoplastic reduction pattern technique following removal of a giant breast lipoma.

We present a case report of a 59-year-old patient with a giant lipoma of the left breast, extending to the left arm. She sought medical consultation because it had become heavy and caused pronounced breast asymmetry. The lesion was excised by means of an oncoplastic technique using the superior-medial pedicle wise-pattern breast reduction approach. We concluded that the use of the oncoplastic reduction pattern technique after removal of a giant breast lipoma is highly rewarding, resulting in a smaller-sized breast that is aesthetically more pleasing, has better symmetry with the contralateral breast, and provides relief from functional mass deficit. This technique minimizes the potential for a breast deformity once the tumor is resected.

A review of the applications of the hydrofiber dressing with silver (Aquacel Ag) in wound care.

Aquacel Ag((R)) (ConvaTec, Princeton, NJ, USA) is a new hydrofiber wound dressing consisting of soft non-woven sodium carboxymethylcellulose fibers integrated with ionic silver. It is a moisture-retention dressing, which forms a gel on contact with wound fluid and has antimicrobial properties of ionic silver. We present a current literature review on Aquacel Ag((R)), of both in vitro and in vivo efficacy and clinical applications. In vitro and in vivo studies have demonstrated the wide antimicrobial properties of Aquacel Ag((R)), and additionally demonstrated the cytotoxicity of ionic silver to keratinocytes and fibroblasts that cause delay in wound re-epithelialization. Clinical studies confirmed that Aquacel Ag((R)) is an effective and safe dressing for a variety of wound types, both acute and chronic. Incorporation of ionic silver into the hydrofibers does not cause undue alteration in the performance properties of the base dressing, which continues to provide favorable wound moisture and exudate management. The addition of ionic silver reduces local pain and dressing changes, and provides significant broad-spectrum antimicrobial properties, with no delay in wound healing.

Treatment of earlobe keloids by extralesional excision combined with preoperative and postoperative "sandwich" radiotherapy.

BACKGROUND: Earlobe keloids can form after cosmetic ear piercing, trauma, infection, or burns, or spontaneously. These keloids are highly resistant for treatment and are followed by severe cosmetic implications. There are various surgical and nonsurgical treatment modalities for earlobe keloids, with no universally accepted treatment policy and a wide range of reported recurrence rates. The authors present their experience of treating earlobe keloids using the "sandwich" technique protocol; extralesional excision and external-beam radiotherapy are given a day before and a day after the operation. METHODS: The authors retrospectively reviewed all patients with earlobe keloids treated by the "sandwich" technique between the years 1996 and 2005. Patients were categorized into two groups: a high-risk group for previously treated patients and patients with a tendency for hypertrophic scars and keloids, and a low-risk group for the others. All patients underwent extralesional excision of the keloid and local radiotherapy before the excision and following it. Follow-up was a minimum of half a year and included a patient satisfaction questionnaire and documentation of keloid recurrence or cure. RESULTS: A total of 23 patients were treated by this protocol; 57 percent were male. Patients had an average age of 24 years. The most common keloid etiology was earlobe piercing. Recurrence rates for the low-risk and high-risk groups were 25 and 27 percent [percent of the patients], respectively. Overall patient satisfaction was high. CONCLUSION: The combined excision and "sandwich" radiotherapy technique is a simple and effective method for treating earlobe keloids, with high patient satisfaction and low recurrence and complication rates.

Comprehensive approach in surgical reconstruction of facial nerve paralysis: a 10-year perspective.

Facial paralysis presents diverse functional and aesthetic abnormalities. Reconstruction may be achieved by several methods. We reviewed the management and outcome of facial paralysis patients to establish principles on which a comprehensive reconstructive approach may be based. Records were reviewed of all patients operated for facial paralysis at our institution between 1998 and 2007. Ninety-five patients were included, of which 15 patients had static reconstruction alone, and 80 patients had dynamic reconstruction. Presented is our experience in reconstruction of facial paralysis over the past decade, delineating a comprehensive approach to this condition. Various surgical techniques are described.

Malignant melanoma and pregnancy: second thoughts.

Malignant melanoma (MM) was considered a hormone-sensitive tumour, and pregnancy was thought to increase its risk and cause faster progression and earlier metastasis. Several controlled studies demonstrated similar survival rates between pregnant and non-pregnant patients and concluded that early reports of advanced MM of pregnancy were probably due to late diagnosis. We retrieved information from our database between 1997 and 2006 on all patients diagnosed as having MM during and up to 6 months after pregnancy (n=11) and compared them to age-matched, non-pregnant, MM patients (n=65, controls) treated by us during that period. The mean Breslow thickness was 4.28mm for the pregnant patients and 1.69mm for the controls (p=0.15). The sentinel nodes were metastatic in five pregnant patients compared to four controls (p<0.0001). Two patients in the pregnancy group and one control died of MM (p=0.0532). Our results indicate a negative effect of pregnancy on the course of MM.

Large-volume breast reduction: Long-term results.

Forty-three women had reduction mammaplasty during the period 1992-2000 and the cosmetic outcome was evaluated using subjective and objective measures. The inferior pedicle technique was used in all cases. The mean (SD) weight of resected tissue was 1121 (415) g. All objective measurements were within the ideal range except for breast volume and nipple-to-inframammary-line distance, which were more than ideal. Overall, the median difference in measurements between the two breasts of each woman was less than 10%. However, the subjective evaluations given by both clinicians and the patients for overall symmetry and for general aesthetic appearance fell below the preset threshold. The shape of the breast correlated best with the grades of symmetry and general appearance. There was no correlation between the objective and subjective evaluations of symmetry. The disappointing subjective scores, which may be attributed to the specific characteristics of our sample group, are heavy breasts and overweight patients, a double team approach, and the inevitable pseudoptosis that develops with the inferior pedicle approach. These direct us to recommend searching for an alternative operative technique and to evaluate its long term results, as well as placing the nipple-areola complex lower than the standard inframammary fold projection.

Allergenicity resulting from functional mimicry of a Toll-like receptor complex protein.

Aeroallergy results from maladaptive immune responses to ubiquitous, otherwise innocuous environmental proteins. Although the proteins targeted by aeroallergic responses represent a tiny fraction of the airborne proteins humans are exposed to, allergenicity is a quite public phenomenon-the same proteins typically behave as aeroallergens across the human population. Why particular proteins tend to act as allergens in susceptible hosts is a fundamental mechanistic question that remains largely unanswered. The main house-dust-mite allergen, Der p 2, has structural homology with MD-2 (also known as LY96), the lipopolysaccharide (LPS)-binding component of the Toll-like receptor (TLR) 4 signalling complex. Here we show that Der p 2 also has functional homology, facilitating signalling through direct interactions with the TLR4 complex, and reconstituting LPS-driven TLR4 signalling in the absence of MD-2. Mirroring this, airway sensitization and challenge with Der p 2 led to experimental allergic asthma in wild type and MD-2-deficient, but not TLR4-deficient, mice. Our results indicate that Der p 2 tends to be targeted by adaptive immune responses because of its auto-adjuvant properties. The fact that other members of the MD-2-like lipid-binding family are allergens, and that most defined major allergens are thought to be lipid-binding proteins, suggests that intrinsic adjuvant activity by such proteins and their accompanying lipid cargo may have some generality as a mechanism underlying the phenomenon of allergenicity.

Paravertebral turnover flaps for closure of large spinal defects following tethered cord repair.

Reconstruction of large congenital spinal defects remains a challenge. We present our experience in closure of difficult spinal defects following repair of tethered cord, using paravertebral fascial or myofascial turnover flaps. Between 1996 and 2005, 23 patients were operated using paravertebral turnover flaps for closure of large spinal defects associated with tethered cord. Fifteen (65%) patients had lipomyelomeningoceles. Eleven (48%) patients had sacral defects, 10 (43%) had lumbosacral defects, and 2 (9%) had lumbar defects. Fourteen (61%) patients underwent closure using fascial turnover flaps. Myofascial turnover flaps were used in 9 (39%) patients. Following surgery, none of the patients developed cerebrospinal fluid (CSF) leaks, pseudomeningoceles, or subcutaneous infection. One patient suffered superficial necrosis and infection of the skin suture line, which healed secondarily. We conclude that fascial or myofascial paravertebral turnover flaps provide reliable coverage of difficult defects of the spinal CNS.

Delayed primary closure of fasciotomy wounds with Wisebands, a skin- and soft tissue-stretch device.

BACKGROUND: Fasciotomy incisions for limb compartment syndrome usually cannot be closed primarily. The conventional method of wound closure with split-thickness skin grafting is effective, but it results in an insensate and disfiguring wound and is associated with donor site morbidity. We present our experience in delayed primary closure of fasciotomy wounds with Wisebands (WB), a skin- and soft tissue-stretching device. PATIENTS: Between 2000 and 2003, we treated 16 patients with extremity fasciotomy wounds for which primary closure was not feasible. RESULTS: The Wisebands devices achieved controlled stretching of the wound edges, including skin and underlying soft tissue, until primary closure was feasible. Fourteen patients (88%) had successful wound closure, two patients (12%) had minor wound complications that did not necessitate the removal of the device, and two patients had local wound complications (infection, intractable pain) and their devices were removed prematurely. Delayed primary closure was achieved at the initial surgery using intraoperative skin stretching in 3 of the 14 cases (21%). After a 2-year follow-up (1.3-4 years), the treated area showed stable scarring with good aesthetic outcome and no functional deficit. CONCLUSIONS: The Wisebands device facilitates closure of fasciotomy wounds with low complication rates and good functional and aesthetic outcome. Its application is simple and safe and requires a short learning curve. Nevertheless, appropriate patient selection, intraoperative judgment and close postoperative supervision are essential for optimal results.

Clinical comparative study of aquacel and paraffin gauze dressing for split-skin donor site treatment.

The management of split-thickness skin graft donor sites is targeted towards promoting the healing process, while minimizing adverse effects and complications. The aim of this study was to compare donor site treatment outcome between Aquacel, a carboxymethylcellulose-based hydrofiber dressing, and the standard mesh paraffin gauze dressing. The study included 23 adult patients. Half of the skin graft donor site in the proximal thigh was dressed with paraffin gauze and the rest with Aquacel. The results indicated that patients treated with Aquacel experienced significantly less pain and a more rapid rate of epithelialization compared with patients treated with mesh paraffin gauze dressing. Final scarring (ie, after the 1-year follow-up) was significantly better with the Aquacel dressing. We conclude that Aquacel dressing is superior to the standard mesh paraffin gauze dressing for split-thickness donor site area in pain relief, ease of treatment, promotion of epithelialization, and the quality of scarring.

Our experience with Wisebands: a new skin and soft-tissue stretch device.

Complex wounds that involve skin and soft-tissue defects that are unsuitable for primary closure by conventional suturing are common in the field of surgery. Among the many surgical options available to overcome these problems are various mechanical devices that have recently been proposed for delayed primary closure of such wounds. The authors present their experience with a new complex wound closure device, Wisebands, a device uniquely designed for skin and soft-tissue stretching. During the last 2 years, the authors have treated 20 patients with 22 skin and soft-tissue wounds for which primary closure was not feasible. The Wisebands devices were applied to the wounds, stretching the skin and underlying soft tissue, gradually closing the defects until the edges were sufficiently approximated for primary closure. Successful wound closure was achieved in 18 patients (90 percent). The Wisebands devices were removed in two patients (10 percent) because of major wound complications. In two other patients (10 percent), minor wound complications had occurred that did not necessitate removal of the device. At a mean follow-up of 1 year (range, 10 months to 2 years), stable scarring with no functional or significant aesthetic deficit was achieved. The authors conclude that the Wisebands device facilitates closure of complex skin and soft-tissue wounds, with low morbidity and complication rates, and can provide the surgeon with another important tool for closing complex wounds. Nevertheless, appropriate patient selection, intraoperative judgment, and close postoperative care are essential to ensure closure and avoid undue complications.

Photodynamic therapy for Bowen's disease and squamous cell carcinoma of the skin.

BACKGROUND: Photodynamic therapy involves the activation by visible light of a previously administered photosensitizing agent in order to cause tumor necrosis. Skin tumors can be treated with topical photosensitizers and thus avoiding systemic side effects. In this study we evaluate the immediate and long-term effects of photodynamic therapy (PDT), using aminolevulinic acid (ALA) as a photosensitizer and a non-laser light source, on Bowen's disease (intra-epithelial squamous cell carcinoma) and on frank squamous cell carcinoma (SCC) of the skin. METHODS: ALA in cream form (20%) was topically applied on biopsy-proven Bowen's disease or SCC of the skin. The lesions were covered with occlusive and light-shielding dressing. Sixteen hours later, they were submitted to a 10-min light session using Versa-Light™, a non-laser light source (spectral output of 580-720nm and 1250-1600nm, 100J/cm(2)). The initial evaluation was done 21 days post-treatment and every 3m thereafter. Patients that did not respond to treatment after two to three sessions were referred to surgery. RESULTS: Forty Bowen's disease lesions (24 patients) and 43 SCC lesions (18 patients) underwent treatment. Median follow-up was 21±8m. No patient had any remarkable side effects. Thirty-four Bowen's disease (85%) lesions completely responded as did 32 SCC lesions (74%). CONCLUSIONS: Our findings showed that PDT is highly effective in treating Bowen's disease and SCC lesions and can be used as a first treatment modality in so far as its use does not preclude the subsequent surgery recommended for the small percentage of failures.

Chronic radiodermatitis injury after cardiac catheterization.

The authors present two patients in whom chronic radiodermatitis developed after repeated cardiac catheterization and coronary angioplasty procedures, with no indication of malignancy. In one patient, after other therapeutic methods were unsuccessful in alleviating his symptoms, the authors excised the lesion with wide surgical margins and skin grafted the area. The mere purpose was to free the patient from the unrelenting pain and discomfort. In this case, the authors achieved complete success in wound healing but only partial success in pain relief.

Does heart rate identify sudden death survivors? Assessment of heart rate, QT interval, and heart rate variability.

The objective was to test whether the circadian variability of several electrocardiographic variables distinguishes sudden cardiac death survivors from heart disease patients without a history of cardiac arrest and from normal subjects. Heart rate, heart rate variability, and QT interval have been reported to identify survivors of sudden cardiac death. Computer-assisted continuous QT measurement and heart rate variability analysis were performed on 24-hour Holter records for three groups: (1) 14 sudden death survivors; (2) 14 control patients with diagnosis and therapy matched to survivors; and (3) 14 healthy subjects. There were no significant differences in 24-hour mean RR and QT intervals between groups. However, heart rate was significantly different between the three groups at night but not during the day because the expected nighttime decline was markedly blunted in survivors and somewhat blunted in control patients. The QT interval and frequency domain heart rate variability measures followed a similar circadian pattern. The mean QTc was significantly longer in control patients. The QTc had a wide range in all groups, but less in sudden death survivors. Of ten common time and frequency domain heart rate variability indices, only SDANN and SDNN were significantly lower in sudden death survivors. Reduced circadian variation of heart rate, with marked blunting of the nighttime heart rate decline, identifies sudden cardiac death survivors as well as does SDANN and SDNN, and, in contrast to heart rate variability measures, can easily be obtained from a Holter report without complex calculations.