New head-mounted miniaturized microscope in hypospadia surgical correction.

AIM: The aim of this paper was to report our experience using VarioscopeÒM5 in hypospadia surgical correction. To suggest the use of microsurgical principles that can result in the successful repair of hypospadias with a few complications. METHODS: Forty-three patients (age 12-16 months), affected by hypospadia, underwent longitudinal dorsal preputial island flap (Scuderi's technique) surgical procedure. All the procedures were performed with Varioscope®M5. This new device is a head-mounted miniaturized microscope which combines a microsurgical microscope illumination and magnification with the freedom of loupes. RESULTS: In 39 (91.1%) of the patients the postoperative course was uneventful. One patient (2.3%) developed urethral fistula and a second intervention was necessary to correct it. He was affected by fourth degree hypospadia. In 3 patients (6.6%) we observed a mild stenosis. Urethral strictures were dilated during multiple sessions, by weekly introduction of catheters of progressively increasing caliber. At 3 months after surgery all urethral strictures had been solved by non surgical treatment, thus decreasing complication rate of the surgical procedure from 8.9% to 2.3%. Evaluation of flow rate was repeated at 3 weeks, 6 and 12 months. The aesthetic outcome was evaluated by the parents on a VAS scale. Results were judged optimal (8-9 out of 10). CONCLUSION: In order to achieve a better aesthetic and functional outcome and to reduce complications we deem a perfect flap dissection and anastomosis necessary. A well lighted and magnified surgical field is essential to achieve the best result due to the small anatomical structures involved in the surgical technique we have adopted. The Varioscope®M5 offers essential advantages in this regard.

Extracranial association of arteriovenous and venous malformations. Case report.

Association of multiple vascular malformations of the face is a rare condition. An arteriovenous malformation (AVM) with a venous malformation as the draining vein is also a rarity. We report a case of extracranial mixed vascular malformations that deformed the normal architecture of the lower face. Removal of the AVM was followed by stability of the jaw and tongue malformation, indicating the AVM used the venous malformation as its draining vein. This approach spared the patient severe cosmetic and functional sequelae.

Evaluation of negative pressure vacuum-assisted system in acute and chronic wounds closure: our experience.

Negative-pressure therapy or vacuum-assisted closure (VAC) has been used in clinical applications since the 1940's and has increased in popularity over the past decade. This dressing technique consists of an open cell foam dressing put into the wound cavity, a vacuum pump produces a negative pressure and an adhesive drape. A controlled sub atmospheric pressure from 75 to 150 mmHg is applied. The vacuum-assisted closure has been applied by many clinicians to chronic wounds in humans; however it cannot be used as a replacement for surgical debridement. The initial treatment for every contaminated wound should be the necrosectomy. The VAC therapy has a complementary function and the range of its indications includes pressure sores, stasis ulcers, chronic wounds such as diabetic foot ulcers, post traumatic and post operative wounds, infected wounds such as necrotizing fasciitis or sternal wounds, soft-tissue injuries, bone exposed injuries, abdominal open wounds and for securing a skin graft. We describe our experience with the VAC dressing used to manage acute and chronic wounds in a series of 135 patients, with excellent results together with satisfaction of the patients.

["Skin reducing mastectomy" and immediate breast reconstruction with Becker 35 contour profile breast implant: our experience]. / "Skin reducing mastectomy" e ricostruzione immediata con protesi/espansore Becker 35 contour profile. Nostra esperienza.

AIM: We describe in this paper our experience with the technique of skin-reducing mastectomy in the treatment of breast cancer. METHODS: Between October 2005 and April 2010 in our Center 33 patients underwent breast surgery utilizing the skin-reducing mastectomy technique and immediate breast reconstruction with expansor/definitive implant Becker 35 contour profile. Contralateral symmetrization was performed in the same operation. All selected patients satisfied inclusion critera either for nipple-sparing mastectomy or prophylactic mastectomy. We selected patients who had large ptosic breasts: areola-submammary fold >8 cm and jugular-nipple distance >25 cm. After histologic exam to confirm the lack of retroareolar tissue infiltration the nipple was preserved in a superior flap. RESULTS: Twenty-four out of 33 patients (72.7%) did not suffer from complications. In 9 patients (27.3%) we observed early complications. During follow-up we observed in 24 patients (72.7%) Baker I capsular contracture, in 9 patients (27.3%) Baker II capsular contracture. Esthetic results of symmetry, shape and volume were good to optimal. Patients' satisfaction was similar. During the follow up (6-33 months, average 17.7 months) no patient suffered from breast cancer recurrence. CONCLUSION: The "skin-reducing mastectomy" reduces mutilation and unsightly scar visibility. It gives a pleasant aesthetic outcome without hindering oncological safety.

Comparative analysis between nasolabial and island pedicle flaps in the ala nose reconstruction. Prospective study.

The goals of reconstructing deformities of the face secondary to skin cancer include reconstructing the area with similar tissue. The comparison between different types of local flaps for reconstruction of nasal ala is presented in a prospective, randomized study. The objective of this study was to compare the functional and esthetic outcomes between the nasolabial and island flaps. A total of 60 patients with skin cancer of the nose underwent ala reconstruction: 30 cases by nasolabial flap (group A) and 30 by island flap (group B). The two groups were homogeneous for sex, age, and anatomical area. Complications, scarring according to the scale of Vancouver, cosmetic appearance, and disorders of sensations were analyzed and statistical analysis was performed. In group A, early complications were more common than in group B. The scars of group B patients were more like those of undamaged skin. A total of 10% patients of group A evaluated the cosmetic appearance of their nose as very good, while in group B, 30% patients gave such an evaluation. Local flaps provide better reconstruction and the island flap appears to have more efficacy when compared with nasolabial flap for nasal ala reconstruction.

[The distally based sural neurocutaneous flap in reconstruction of lower limb: our experience]. / Il lembo neurocutaneo surale a base distale nella ricostruzione dell'arto inferiore: nostra esperienza.

BACKGROUND: Our study concerns eight patients who have undergone surgery at the Department of Plastic, Reconstructive and Aesthetic Surgery of the University of Perugia, for the reconstruction of lower limb using the distally based sural neurocutaneous flap for covering loss of substance of various origin, from October 2007 to November 2009. PATIENTS AND METHODS: The aim of our study is to demonstrate the reliability of distally based neurocutaneous sural flap in reconstruction of lower limb following a loss of substance of different nature involving the lower third of the leg. Eight patients were on systemic and local clinical conditions that can not be undergoing surgery with use of free flap. In five patients (62%) the loss of substance had been caused by traffic accident while another patient (12%) had been the victim of an accident at work. Two patients (26%) had suffered from pressure ulcers and were unstable with regard to the vascularisation. RESULTS: We observed no cases of total necrosis of the flap and in all eight patients we showed good healing. Follow up was 2, 4, 6, and 9 months after surgical intervention. CONCLUSION: Our study has shown that the use of the distally based sural neurocutaneous flap in reconstruction of lower limbs, as a salvage procedure, is still a valid alternative procedure to free tissue transfer. Because of reduced operative times, reduced anaesthetic risk, reduced risk of total flap necrosis and reduced costs, it could be considered as a preferable choice in selected cases.

L-specular plasty versus double-round plasty: two new techniques for earlobe split repair.

BACKGROUND: Split earlobes can be classified into two groups: congenital and traumatic. The congenital group can be divided into three categories: anterior, posterior with doubled earlobe, and sagittal. The traumatic group can be divided into two categories: complete and incomplete. This report describes and compares two new techniques the authors have developed for split earlobe repair: L-specular plasty and double-curve-specular plasty. Both techniques are simple to perform and deliver a good aesthetic result. METHODS: A series of 30 patients with split earlobes underwent surgery from September 2007 to September 2009. All the patients enjoyed good health with no organic pathologies. All the patients had surgery under local anesthesia. The L-specular plasty technique was used to treat 15 patients (13 complete splits, 2 incomplete splits). The remaining 15 patients (13 complete splits, 2 incomplete splits) were treated with the double-curve-specular plasty. RESULTS: Skin necrosis was not reported for any of the treated patients. Sutures are completely removed after 2 weeks. The sutures for three patients were removed after 20 days due to slow cicatrization. Repiercing of the ear may occur after 6 months. One patient (8%) experienced a wound infection, treated successfully with systemic antibiotic therapy. Two patients (16%) experienced hypertrophic scars. Only two patients (16%) had recurrence during a mean follow-up period of 13.4 months (range, 6-24 months: September 2007-2009). CONCLUSION: Both double-curve-specular plasty and L-specular plasty are simple, reliable procedures. They both deliver very good aesthetic results thanks to the curve incisions that follow the natural shape of the earlobe. However, the patients treated with double-curve-specular plasty reported greater satisfaction in the outcome of their surgery.

[Aminoacids and hyaluronic acid in topical treatment of bedsores. Clinical report]. / Il trattamento topico di ulcere da pressione con aminoacidi e acido ialuronico. Caso clinico.

Pressure ulcers are evolutive tissue of the skin, derma and subcutaneous layer. If not treated properly, but sometimes despite that, they may even reach muscles and bones. Nutritional status of the patient is the most important and potentially reversible factor which can contribute to wound recovery. Several studies underline in particular the importance of the proteic and caloric intake in order to stimulate the formation of granulation tissue and collagen. We thought giving the nutrients for wound repair directly on the wound bed, topically, therefore using the wound bed as exchange surface and presuming the wounded tissues are able to absorb, metabolize and ultimately use the aminoacids to repair the damage. The goal of our work is to describe the clinical case patient treated with a new active wound dressing releasing aminoacids and hyaluronic acid.

The use of pectoralis major myocutaneous flap as "salvage procedure" following intraoral and oropharyngeal cancer excision.

BACKGROUND: The benefits and superiority of free flaps for head and neck reconstruction are well recognized. However, in some instances, especially in elderly and critical patients with advanced intraoral and oropharyngeal cancers or in patients with underlying systemic syndromes (i.e. uncontrolled diabetes, cardio-pulmonary failure, renal insufficiency), the use of pectoralis mayor myocutaneous flap may be a preferable option with fewer risks for the patient. PATIENTS AND METHODS: We present a series of 12 pectoralis major myocutaneous flaps, performed from January 2007 to June 2008, in 12 critical patients who presented with advanced carcinomas of the oral cavity and oropharynx. In all cases, histology showed (T3-T4)-(N0-N3)-M0 squamous cell carcinomas. Tumors were: 4 intraoral (33%), 2 in the oropharynx (16%), 5 in the hypopharynx (41%) and 1 of the skin left auricle (8%). RESULTS: There were no flap loss. Partial skin necrosis (<10%) occurred in 1 case (8%); one patient (8%) developed wound infection treated successfully with systemic antibiotic therapy. Minor oro cutaneous fistulas developed in 2 patients (16%). At the follow-up 4 patients (34%) died after 4 months, 2 patients (16%) had recurrence of disease, 6 patients (50%) showed no evidence of disease. CONCLUSION: The use of pectoralis major myocutaneous flap as a salvage procedure in immediate reconstruction following ablative surgery of head and neck cancers is still a valid alternative procedure to free tissue transfer. Because of reduced operative times, reduced anaesthetic risk, reduced risk of total flap necrosis and reduced costs, it could be considered as a preferable choice in selected cases.

[Leg ulcers in patient affected by polycythemia vera in treatment with hydroxycarbamide. Case report]. / Ulcere cutanee in paziente con policitemia vera in trattamento con idrossicarbamide. Case report.

Leg ulcers are a frequent and serious complication of polycythemia vera (PV). They are caused by a synergic action of vascular, neurological and infectious physiopathologic mechanisms. Furthermore, cytostatic therapies commonly employed to control the myeloproliferative disease negatively interfere on the development of granulation tissue, slowing down the recovery of the ulcer. We describe the case of a 70 years old woman with PV, who had calcaneous and perimalleolar ulcers. They were so painful that they made it almost impossible for her to sleep and walk normally. These ulcers were particularly resistant to common topical therapy. Further and accurate investigations showed that these ulcers were a complication of hydroxycarbamide therapy employed and they were not a complication of the ematologic disease. Leg ulcers during hydroxycarbamide therapy are a relatively frequent but underestimated condition. Pathogenesis is bound to numerous factors, i.o. cellular damage and tissutal hypoxia, consequent of drug induced macroerythrosis. In our patient drug substitution and prosecution of topic therapies allowed the recovery of the leg ulcers, particularly serious for both, extensiveness and symptoms.

["Step technique" in the treatment of the loss of substance of the lower lip]. / Tecnica "a scaletta" nel trattamento delle perdite di sostanza del labbro inferiore.

The most frequent pathology of the lower lip is the neoplastic pathology and squamous cell carcinoma is the most clinically diagnosed. Wide excision is the correct surgical approach but it may cause severe morpho-functional and aesthetic damages. At the Plastic and Reconstructive Department of Policlinico Umberto I, " Sapienza" University of Rome, from 2005 to 2008 36 patients were treated, 19 only by surgical excision (Group I) and 17 by Johanson's technique (Group II). Follow-up was at 6 and 12 months to evaluate the morpho-functional outcome, the asymmetry and the healing. Moreover a questionnaire of 9 items was proposed to patients to evaluate functional and aesthetic results. Data showed that Johansons' s flap achieves the same results of the complete surgical excision but with better morpho-functional and aesthetic outcomes, greater satisfaction and same staying in hospital for patients.

Scrotal calcinosis: a very rare multiple clinical presentation.

Scrotal calcinosis (SC) is a rare benign disease that affects patients in childhood or early adulthood. It is characterized by slow-growing yellowish-white nodules consisting of deposits of calcium and phosphates, within the scrotal skin. The nodules vary in number, and can be solitary or grouped. Owing to the age of onset and anatomical location, SC may be a source of embarrassment and lead to social isolation. Because of its rarity, the aetiology of SC is still controversial. We report a very rare case of an SC in a 59-year-old white man who presented with multiple nodules with different clinical patterns in the scrotum, which had been present for > 42 years. Despite the rarity and the multiple long-lasting lesions, surgical excision of the scrotal nodules can offer a very good aesthetic outcome in a single procedure even under local anaesthesia.

Innovative microsurgical device in perforator free flaps surgery.

Dissection of the small perforating vessels through the muscle/septum can be difficult, and microsurgical success is closely linked on a clear and well-magnified field vision. Since 2004, Varioscope M5 has been employed in our Plastic Surgery Departments. It is the first and only head-mounted microscope. In this study was examined 10 patients underwent to reconstructive procedures by harvest of perforator free flaps, working with Varioscope M5. At long-term follow-up, all patient present an exceptional outcome. Considering cost-effectiveness, portability, operator freedom, and effectiveness in the perforator flaps dissection and in the anastomosis making, we think that Varioscope M5 offers essential advantages Dissection of the small perforating vessels through the muscle/septum can be difficult, and microsurgical success is closely linked on a clear and well-magnified field vision. Since 2004, Varioscope M5 has been employed in our Plastic Surgery Departments. It is the first and only head-mounted microscope. In this study was examined 10 patients underwent to reconstructive procedures by harvest of perforator free flaps, working with Varioscope M5. At long-term follow-up, all patient present an exceptional outcome. Considering cost-effectiveness, portability, operator freedom, and effectiveness in the perforator flaps dissection and in the anastomosis making, we think that Varioscope M5 offers essential advantages.

[Multicentric study on a topical compound with lymph-draining action in the treatment of the phlebostatic ulcer of the inferior limbs]. / Studio multicentrico su un preparato topico ad azione linfodrenante nel trattamento dell'ulcera flebostatica degli arti inferiori.

Phlebostatic sore of the lower limbs is a typical chronic venous insufficiency complication and is still a widely controversial issue in its treatment. The common therapies, in fact, are not yet standardized and they not show complete efficacy. Since 2005 to 2007 a multicentric clinical trial was conducted at the Plastic and Reconstructive Surgery of "Sapienza" University of Rome and at the Plastic and Reconstructive Surgery Department, University of Perugia, in order to evaluate the efficacy of the Idrastin lymph-draining cream in patients with phlebostatic sores of the lower limbs. This study enrolled on 80 patients, split into 2 homogeneous groups of 40 patients: group A was treated by only elastocompressive therapy, group B by elastocompressive therapy and Idrastin. Multicentric analysis has considered the following parameters: local pain, perilesional flogosis , granulation tissue, perilesional tissue tropism healing time. In the group B results highlighted: reduction of the local pain, stopped in 72 hours; flogosis decrease disappeared in one week; tissue granulation growth in one week; lesion healing in 4 weeks. These results pointed out statistically significance of the variables considered. In our opinion Idrastin compounds such as phytoessence of hops and Hedera helix, had contributed to analgesia; Aesculus hippocastanum, and Vitis vinifera and Ruscus aculeatus phytoessence showed anti-flogistic action; allantoin and Centella asiatica and jaluronic acid aided to sore healing. Idrastin gives an effective support to the treatment of the phlebostatic sores warrants a faster and more effective healing process, than to the wounds treated by only the elastocompressive therapy.

An approach to managing non-melanoma skin cancer of the nose with mucosal invasion: our experience.

CONCLUSIONS: The absence of recurrences after final nasal reconstruction demonstrates the reliability of our three-stage strategy and the necessity to delay nasal reconstruction, focusing attention on oncological safety for nasal non-melanoma skin cancer (NMSC) with mucosal invasion. OBJECTIVES: To validate a therapeutic strategy aimed at oncological safety and minimization of possible recurrences after full-thickness excision of nasal NMSC with mucosal invasion. The strategy was divided into three stages: surgical excision with clinically safe perilesional skin margins and extemporary frozen section histological control; 8-15 months follow-up leaving the nasal defect unreconstructed with a 'wait and see' strategy; new extemporary histological control of defect margins and, if negative, definitive reconstruction. PATIENTS AND METHODS: Twenty patients affected by nasal NMSC with mucosal invasion were treated and followed up. RESULTS: Basal cell carcinoma was the most common lesion (75%), followed by squamous cell carcinoma (25%). Ultrasonography excluded lymphatic involvement for SCC. Before final reconstruction, extemporary histological examination revealed the presence of tumour cells in three patients. After tumour extirpation, these patients were resubmitted to a new follow-up period before reconstruction. No recurrences were observed after definitive nasal reconstruction in all patients during the 5-year follow-up.

[Oncological and reconstructive management in a patient with multiple recurrences of basal cell carcinoma of the nose]. / Management oncologico e ricostruttivo nella recidiva multipla del carcinoma basocellulare del naso.

Basal cell carcinoma (BCC) grows by direct extension replacing local anatomical structure; it rarely metastasizes, however may cause severe injure expanding to contiguous tissues with a biological invasive behaviour. BCC of the nose is often a highly aggressive neoplasia with infiltrative growth pattern. Fast cancer extension to the adjacent facial structures requires wide resection for oncological management. In our study we present a 69-year-old male affected by BCC of the nose back and treated by surgical radical excision with free margin disease at histological examination. Patient, subsequently, developed a local relapse. Therefore, he underwent surgical excision of the recurrence and the histological evaluation pointed out a metatypical and infiltrative BCC pattern without margins involvement. Afterwards, the patient developed another local recurrence involving the left alar nose and the omolateral cheek. Histological examination still demonstrated a metatypical and infiltrative pattern, with disease free margins, but nasal vestibule involvement. Successively the patient had another local wide resection from the nasal wing to the maxillary bone without reconstructive procedure. Three years after, the patient developed another local relapse and underwent another surgical procedure, consisting in a very wide resection with concomitant selective left laterocervical node dissection. Histological evaluation demonstrated a metatypical solid infiltrative BCC pattern with disease free margins and lymph nodes. One year after, forehead flap was made to reconstruct the nose and left cheek deficit. At 16 months follow-up the patient remains disease free.

Breastfeeding after reduction mammaplasty using different techniques.

BACKGROUND: This study reviewed mammary glandular function and breastfeeding after reduction mammaplasty performed via four different surgical techniques. Patients who underwent this procedure were asked to answer questions concerning the birth of a child, natural breastfeeding, and the reasons why natural breastfeeding was not performed or was interrupted. METHODS: Between 1992 and 2001, 368 reduction mammaplasties were performed in the Department of Plastic Surgery at the "La Sapienza" University of Rome. After reduction mammaplasty, 105 patients had a child and were enrolled in the study. Breastfeeding data were compared with data from hospital records at the time of surgery in terms of patient age, reduction mammaplasty technique, sensitivity of the nipple-areola complex after the operation, and proportion of the gland removed. RESULTS: Maternal breastfeeding was considered to have occurred if it lasted more than 3 weeks and was not accompanied by any nutritional supplements. Babies were breastfed by 60.7% of the patients who underwent a superior pedicle reduction mammaplasty, by 43.5% of those who underwent an inferior pedicle reduction mammaplasty, by 48% of those who underwent a medial pedicle reduction mammaplasty, and by 55.1% of those who underwent a lateral pedicle reduction mammaplasty. CONCLUSIONS: The findings demonstrate that conservative reduction mammaplasty techniques supported by medical and paramedical staff permit subsequent breastfeeding. In particular, the best outcomes resulted from superior pedicle reduction mammaplasty. Skilled execution of the surgical technique is mandatory to guarantee adequate vascularization and sensitivity of the nipple-areola complex and to spare as many of the glandular ducts and lobules as possible.

Lateral canthoplasty--10-year experience.

Lateral canthoplasty is a useful method to restore eyelid function and to protect the ocular surfaces. The success of the procedure depends on the proper analysis of periorbital anatomy as it relates to the specific indication for lateral canthoplasty. We report the experience with 129 lateral canthoplasties with emphasis on the evaluation of newer techniques that better address anatomic and functional requirements. Between 1994 and 2004, 129 lateral canthoplasties were performed in 105 patients, only for reconstructive purpose. A variety of surgical techniques have been described for lateral canthoplasty, and the evolution of the operative technique for lateral canthoplasty has been toward an operation that corresponds with the anatomy of the individual. Indications for the procedure include senile ectropion, tumors, cicatritial retraction, trauma, entropion, and congenital cleft. The evaluation of the newer procedures of lateral canthoplasty as unique reconstructive tools will be discussed.

Cryotherapy in the treatment of keloids.

BACKGROUND: Despite their benign nature, keloids may constitute a severe aesthetic and, in some cases, functional problem with important repercussions on patients' quality of life. There is no consensus on keloid treatment and no wholly satisfactory therapy has yet emerged. OBJECTIVE: To assess the efficacy of cryotherapy in the treatment of keloids. METHODS: 135 patients with 166 keloids received cryosurgical treatment between 1990 and 2004. Freeze times and number of sessions varied. Scar volume was measured before and after treatment. Median follow-up was 48.6 months (range 12.4-72.6 months). RESULTS: Of the 166 lesions treated, 79.5% responded very well with a volume reduction of the initial mass of greater than 80% after a median of 3 treatments (range: 1-9). A good result was obtained in 14.5% of lesions, while results were unsatisfactory in 6% of cases. The main adverse effects reported were atrophic depressed scars and residual hypopigmentation (75% of cases). No recurrences arose during the follow-up period (12-72 months). CONCLUSIONS: To date, cryotherapy appears to be the most effective, safe, economic, and easy-to-perform monotherapy to treat keloid lesions and hypertrophic scars.