Successful combined approach to a severe Fournier's gangrene.

We present a case of a successful reconstruction of a severe Fournier's gangrene (FG) involving the scrotum, the perineum, the right ischial area and extended to the lower abdomen. There are many different surgical techniques to repair and reconstruct the defect following debridement in FG. The authors treated this complex wound using negative pressure wound therapy (NPWT), dermal regeneration template and a split-thickness skin graft. Complete recovery was achieved and no major complications were observed. The patient showed a satisfying functional and aesthetic result.

Head and neck polypoid melanoma.

Polypoid melanoma represents a rare clinical variant of nodular melanoma skin cancer in which the tumor is connected to the skin by a pedicle, characterized by exophytic growth, ulceration, and young age at onset (20-39 years) with a special predilection for the back and with a survival rate at 5 years ranging from 32% to 42% as compared with 57% 5-year survival for nodular subtype and 77% for the superficial subtype. We present a case of a deeply pigmented polypoid melanoma arising on the face of a 77-year-old man. We performed a literature review to clarify its surgical management and prognosis.

Contrast-enhanced ultrasound: a filter role in AJCC stage I/II melanoma patients.

One of the most significant advances in melanoma staging is sentinel lymph node biopsy (SLNB). It is a surgical technique to detect occult nonpalpable micrometastases in regional lymph nodes. Recently, contrast-enhanced ultrasound (CEUS) was introduced as a noninvasive procedure, in spite of SLNB, for the detection of SLNs in patients with cutaneous melanoma. The main purpose of this study was to evaluate the diagnostic accuracy of CEUS in the diagnostic workup of patients with melanoma in comparison with the final histology of SLNs detected through preoperative lymphoscintigraphy. Fifteen patients with cutaneous melanoma underwent prompt excisional biopsy with narrow margins in order to avoid impairment of the melanoma lymphatic basin and were referred for SLNB according to routine indications between January and February 2009. In our study CEUS showed, albeit based on a small patient sample, a negative predictive value of 100%, that means that all negative results were confirmed by negative SLN histopathological examination; all ultrasonographically negative lymph nodes corresponded to nonmetastatic sentinel nodes.

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength.

BACKGROUND: Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS: To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS: Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION: The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

Circumferential abdominoplasty.

BACKGROUND: In Italy, 34.2% of the population has a BMI higher than 25, and another 9.8% of the population has a BMI higher than 30. In Italy, there are 4 million and 700,000 obese people. Bariatric surgery has evolved as a very effective therapy for morbid obesity. After such dramatic weight loss, patients are usually left with redundant skin and unwieldy subcutaneous tissue. The circumferential truncal excess cannot be corrected by a regular abdominoplasty alone. In this group of patients, lateral excess can actually be over accentuated by a traditional abdominoplasty. In our institution, we are used performing abdominoplasty according to Pascal-Le Louarn's surgical technique. In our cases, the adoption of this technique has been successful with a high rate of very satisfied patients, no major complications and few minor complications primarily in the smoker patients. METHODS: The charts of 41 consecutive circumferential abdominoplasty were reviewed. The preoperative markings, the surgical technique, the post-operative course, and the complications are described. RESULTS: The average operative time was 220 min. The average lipoaspirate was 1,600 cc. The mean weight loss during the surgery was 3.4 kg. There were 18 immediate complications, including 11 seromas, and 7 partial wound dehiscences. There were 26 late complications, including 8 hypertrophic scars and 18 local hypoestesia. All seromas were resolved within 3 weeks. All patients were satisfied. CONCLUSION: Circumferential abdominoplasty performed with Pascal-Le Louarn's surgical technique is an effective, appropriate, and safe method to treat patients with lipodistrophy of the trunk following massive weight loss.

Outcome of patients with melanoma and histologically negative sentinel lymph nodes: one institution's experience.

BACKGROUND: Since its introduction by Morton in 1992, sentinel lymph node (SLN) biopsy has become a standard procedure in the staging and treatment of primary melanoma and clinically negative regional lymph nodes. The primary aims of this procedure are to ascertain the individual lymphatic drainage patterns of primary tumors towards 1 or more different lymph node basins and to identify patients with micrometastatic lymphatic disease for selective lymphadenectomy. The aim of our study was to evaluate over time a cohort of patients who, having undergone SLN treatment, were found negative for metastases using routine histopathological and immunohistochemical analyses. METHODS: We studied 102 consecutive patients who underwent intraoperative lymphatic mapping at the Department of Plastic Surgery, University of Florence, Italy, for cutaneous melanoma and were found negative for metastatic melanoma in their SLNs using routine histopathological and immunohistochemical techniques. RESULTS: Of 102 patients with 103 cutaneous melanomas that underwent SLN resection and proved histologically negative to metastasis in that site, 15 patients (14.7%) developed melanoma recurrence during follow-up. CONCLUSIONS: The diagnostic and prognostic value of the absence of melanoma metastases in SLNs may be limited and not particularly significant, since satellite and in-transit metastases or direct distant metastases will not be detected and hematogenous spread may already have begun at the time of intervention.

Inorganic raw materials economy and provenance of chipped industry in some stone age sites of northern and central Italy.

An opportunistic and local choice of raw materials is typically attested in the Lower and Middle Paleolithic industries throughout Italy. The quality of the raw material usually affected the flaking technology and quality of the products. In the Upper Paleolithic and the Mesolithic, raw material procurement strategies were more complex. Flint was exploited both locally, in areas where abundant outcrops of raw materials were available (such as the Lessini mountains), and in distant localities, after which it was transported or exchanged over medium/long distances. Different routes of exchange were thus followed in the various periods; good reconstruction of these routes have been provided by a study of the Garfagnana sites in Northern Tuscany, and the Mesolithic deposit of Mondeval de Sora (Dolomites). An interesting example of a Late Upper Paleolithic flint quarry and workshop were found in Abruzzo, in the San Bartolomeo shelter. The extended trade of obsidian from Lipari, Palmarola and Sardinia to the Italian Peninsula is attested in the Neolithic, with some differences concerning the age and different areas.

A novel combined surgical approach to head and neck dermatofibrosarcoma protuberans.

INTRODUCTION: The surgical management of dermatofibrosarcoma protuberans has historically been a challenge, particularly in the head and neck and other aesthetic areas. The current priority is to achieve local oncologic control and a good reconstructive outcome. Here, we present our experience using a novel combined approach with a dermal regenerative template, sub-atmospheric pressure and skin graft. MATERIALS AND METHODS: Five patients presenting at the Department of Plastic and Reconstructive Surgery of the University of Florence between January 2010 and October 2011 were included in the study following Institutional Review Board approval. All patients underwent a wide local excision of dermatofibrosarcoma protuberans affecting the head and neck. RESULTS: The combined approach using the negative-pressure device, a dermal regenerative template and skin grafting proved effective in the management of this type of sarcoma with a good aesthetic and functional outcome, particularly on the neck or the supraclavicular region. CONCLUSION: Although the present multi-step technique requires patient compliance, it results in good local oncologic control of the resection margins. It is possible to perform a wider excision in the event of positive margins without interfering with the last reconstructive outcome.

Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb.

The standard management of degloving injuries involves either immediate grafting with the avulsed skin or full- or split-thickness grafts at a later date. Alternative methods include pedicle and free flaps and revascularisation. The authors present an innovative technique of treating degloving injuries with cryopreserved split-thickness skin grafts harvested from degloved flap, artificial dermal replacement and vacuum-assisted closure (VAC therapy). To the authors' knowledge, this is the first reported case of such bilaminar reconstruction of a degloving injury.

Wet and dry techniques for structural fat graft harvesting: histomorphometric and cell viability assessments of lipoaspirated samples.

BACKGROUND: Autologous fat transplantation is among the surgical procedures performed most commonly by plastic surgeons for cosmetic and/or reconstructive purposes. In the procedure, autologous fat is harvested and infiltrated during the same operation, and the success of this procedure relies on harvesting and transferring viable adipocytes. This study was designed to assess the histomorphometric characteristics and viability of the lipoaspirated cells that were harvested through different techniques. METHODS: This study enrolled 65 patients undergoing lipofilling for reconstructive purposes. Subcutaneous fat samples were collected manually through the wet and dry techniques using a two-hole Coleman blunt cannula attached to a 10-cc Luer-Lok syringe. Fat tissue preservation was assessed through conventional histomorphometry and a cell viability assessment, evaluating the mitochondrial function through the MTS CellTiter 96 Aqueous One Solution Assay (Promega Corp., Madison, Wis.). RESULTS: No differences were observed between adipocyte samples harvested with or without tumescent solution. The morphometric analysis and adipocyte viability assessment confirmed the visual findings: the mean surface area and shape (circularity index) of the adipocytes were not significantly different in the lipoaspirate collected through the different techniques. CONCLUSION: The results from the present study provide the first histologic evidence and cell viability assessment to demonstrate that there are no substantial differences in the adipose tissue specimens harvested with the wet and dry techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Primary cutaneous osteosarcoma of the scalp: a case report and review of the literature.

We report on an 84-year-old man with a solitary, nodular lesion on the scalp. The patient had been previously submitted to electrodessications of the scalp due to multiple solar keratoses. Histopathologically, the lesion showed features of a high-grade conventional osteoblastic osteosarcoma involving the dermis. Computed tomography showed no involvement of the underlying bone tissues. Clinical examination and extensive total body radiologic workup revealed absence of bone lesions in any body site, thus suggesting a final diagnosis of primary cutaneous extraskeletal osteosarcoma. The clinico-pathological features of the case are discussed in light of the rare cases previously described in the literature.

Autologous lipofilling: coenzyme Q10 can rescue adipocytes from stress-induced apoptotic death.

BACKGROUND: Autologous fat transplantation (or lipofilling) is an excellent technique for correction of cosmetic defects. The success of the procedure relies strongly on the techniques of harvesting and transferring viable adipocytes. The purpose of this study was to evaluate effects of two harvesting methods and coenzyme Q10 on the viability and apoptotic death of adipocytes collected for autologous lipofilling. METHODS: Human adipose tissue from six patients was collected by Luer-Lok syringe according to Coleman's technique or by means of an aspirator with a 680-mmHg vacuum. Half of each sample collected using Coleman's technique was treated with 10 muM Coenzyme Q10, and the other half served as untreated control. Viability and apoptosis were assessed by immunoenzymatic, biochemical, and morphological methods. RESULTS: The harvesting of adipose tissue by aspirator reduced the viability and increased apoptotic death significantly more than harvesting tissue using Coleman's technique. Biochemical and morphological analyses confirmed that treatment of adipose tissue with coenzyme Q10 reduced and even inhibited apoptotic death of harvested adipocytes. CONCLUSION: Coenzyme Q10 can rescue adipocytes from stress-induced apoptotic death.