Paraplegia in a patient with Von Hippel Lindau syndrome: surgical and reconstructive treatment of Marjolin's ulcer. A case report.

STUDY DESIGN: Marjolin's ulcer is a squamous cell carcinoma that develops in posttraumatic scars and chronic wounds. Suspicion of such lesions should be raised in chronic wounds demonstrating characteristic changes. We have reported the peculiar phenomenon of malignant transformation of chronic pressure sores that occurred in a paraplegic patient. OBJECTIVES: The aim of this study was to cover the extensive defects by a last resort reconstructive option. SETTING: Department of Plastic and Reconstructive Surgery, Università Politecnica delle Marche, Ancona, Italy. METHODS AND RESULTS: A 40-year-old paraplegic man, with multiple hemangioblastomas of the brain and spinal cord due to Von Hippel Lindau syndrome developed pressure ulcers with unstable healing over the sacral, trochanteric, bilateral, and ischiatic areas after 15 years from neurosurgery. The biopsy result showed an invasive squamous carcinoma. Carcinomas in pressure sores are highly aggressive, and they need to be treated more radically. In our case we opted for a demolitive surgical treatment including musculocutaneous rotational flap harvested from total left thigh to cover the extensive defects. The limb was previously disarticulated. CONCLUSION: In Marjolin's ulcer, multiple biopsies are the first-line modality for the early diagnosis as they are a safe method with high rate of accuracy. First-line treatment is surgery consisting of radical excision with lymph node dissection, if they are involved. Adjuvant radiation therapy may be used in selected patients. Management of massive pelvic defects can be a challenging problem. The pedicled lower limb flap offers a technique that can be considered as a last resort procedure for extensive defects where other options are insufficient or not available anymore. In our case the patient is disease-free after 2 years of follow-up.

Limb contouring after massive weight loss: functional rather than aesthetic improvement.

BACKGROUND: After massive weight loss, both upper and lower limbs show a similar deformity which consists of redundancy and ptosis of the cutaneous mantle. Many disturbances are associated with this abnormality, which can be treated surgically. A retrospective review of limb-contouring procedures after massive weight loss is presented. METHODS: Thigh lift and arm lift procedures are described. All surgeries of upper and lower limbs contouring performed between 2003 and 2006 are reviewed with regard to quantity of tissue removed, comorbidities, complications and patients' satisfaction, which was surveyed through a questionnaire exploring functional and esthetic results (maximum score 3). RESULTS: Among 48 bilateral limb-contouring procedures, medial thigh lifts were 35 (73%) and brachioplasties were 13 (27%). Mean age was 46 and average body mass index variation was 20 kg/m(2). The most frequent comorbidity was gallstones (28%). In 46% of the whole group of patients, there was no complication to mention. The most frequent complication was acute anaemia in both procedures (43% in thigh lift and 54% in arm lift). Mean quantity of adipose-dermoid tissue removed was 766 g in thigh lift and 463 g in arm lift. In case of surgery combined with liposuction, the average aspirated volume was 1,933 ml (thighs) and 1,117 ml (arms). Patients' satisfaction was 2.7 for thighs and 2.6 for arms, as average. CONCLUSION: The rate of complications in limb contouring after weight loss is higher than the analogue esthetic procedures. Nevertheless, due to the rehabilitative significance of limb surgery after weight loss, this step is to be included as fundamental in obese patients' surgical therapy.

Distally based fasciocutaneous flaps: a versatile option for coverage of difficult war wounds of the foot and ankle.

Early reconstructive treatment of war-related lower extremity injuries can be feasible even when evacuation to ideal tertiary facilities is impossible. However, in such instances, lengthy procedures considered "state of the art" in the everyday civilian practice of plastic surgery are often impractical, and alternative options need to be sought. Undelayed distally based fasciocutaneous flaps of the leg have recently been used in 12 cases of extensive defects of the foot due to antipersonnel mine injuries. All patients, treated during the conflict in Bosnia-Herzegovina, were smokers and were between 17 and 45 years of age. No preoperative arteriography or Doppler was available. One flap was totally lost, and two others suffered tip necrosis. All other cases healed uneventfully. We were impressed at the reliability of distally based fasciocutaneous flaps, even with length-to-width ratios of up to 5:1, and even after distal deepithelialization or tubing of the pedicle. The whole foot can be reached when the appropriate lateral or medial based flap is selected. Obvious disadvantages are the grafted secondary defect of the leg and the lack of sensation, although the latter is a common feature shared by most other flaps to the foot. Also, free-muscle transfer is preferable for very deep defects with extensive bone loss. However, for the ease of dissection, versatility, and short operating time, distally based fasciocutaneous flaps find a definite place in reconstructive trauma surgery.

[Cranioplasty with polymethylmethacrylate. The clinico-statistical considerations]. / Cranioplastica con polimetilmetacrilato. Considerazioni clinico-statistiche.

BACKGROUND: The main purpose of the reconstruction of the cranium is the protection of the brain. Besides we have to consider important functional and aesthetic necessities in order to achieve satisfactory results. METHODS: Thirty-six clinical cases, operated from November 1991 to June 1996, in which the reconstruction of the cranial vault is carried out by a polymethylmethacrylate acrylic resin are analysed. The causes and locations of the most common bone defects and the main indications for reconstruction are examined. While the repair of the osseous gaps caused by neoplasms is immediate, in the traumatic occurrences, in order to reduce the probability of infectious complications, an average time of 11 months elapsed from the first operation. The surgical technique, with slightest alterations, is the same in all the presented cases, preparing the acrylic resin straight on the operating table. The resin, moulded and adapted to the defect until its complete hardening, presents, thanks to its properties, manifold advantages (and few real disadvantages). RESULTS: The results, in terms of complications, are very satisfactory, with an infectious rate of 2.7%. Besides, in one third of the patients, a considerable clinical improvement after the repair has been observed. CONCLUSIONS: According to personal experience, it is possible to affirm that polymethylmethacrylate, with its remarkable plasticity and stability in time, can always guarantee a satisfactory functional and aesthetic result.

The distally based superficial sural flap: our experience in reconstructing the lower leg and foot.

The treatment of soft-tissue defects of the lower third of the leg and foot is often an awkward problem to tackle because of the frequent involvement of muscle, tendon, and bone, which is caused by the thinness and poor circulation of the skin covering them and by the small quantity of local tissue available for reconstruction. The authors present their experience with the use of sural flaps for the treatment of small- and medium-size defects of the distal region of the lower limb. The flap used was a distally based fasciocutaneous flap raised in the posterior region of the lower two thirds of the leg. Vascularization was ensured by the superficial sural artery, which accompanies the sural nerve together with the short saphenous vein. The authors treated 18 patients (12 men and 6 women) from May 1997 to August 1999 at the Division of Plastic Surgery, University of Turin, Italy. Superficial necrosis without involvement of the deep fascia (which was grafted 1 month later) occurred in 1 patient of the 18 treated. In another 2 patients, defects were found in the flap margins, but no additional surgical revision was necessary, and recovery occurred by secondary intention. In every patient the sural flaps provided good coverage of the defects, both from a functional and an aesthetic point of view. The major advantages of this flap are its easy and quick dissection. Because the major arterial axis is not sacrificed, this flap can be used in a traumatic leg with damaged major arteries.

[Fournier's gangrene: remarks on two clinical cases]. / Le gangrène de Fournier: remarques sur deux cas cliniques.

Fournier's gangrene is a genital and perineal necrotizing fascitiis with a rapid evolution. It's an affection caused by aerobic and anaerobic micro-organisms, eventually associated with a superinfection by micetes. It has characterised by a deep oedema associated with lancinating pain and itching in external genitalia, rapidly evolves to perineal tissues necrosis and purulence. At this stadium patient's general conditions are still serious and patient may be comatose. When toxaemia is over, demarcation of necrotic areas can be remarkable and granulation start growing. Fournier's gangrene seems to be related to an ischemic necrosis caused by obliterative endoarteritis and thrombosis of internal pudendal and deep and superficial external pudendal artery. The infection gateway may be subcutaneous tissue lesion associated to trauma or surgical procedures in immunodeficient organism. Diagnosis is mainly clinical but a superficial ecography could be useful to demonstrate thickening in subcutaneous tissue with normal testicles. Both of them were middle aged males, heavy smokers, affected by hypertension and COPD. In both cases there was polymicrobial Gram positive bacterial infection. Antibiotic systemic therapy and topic therapy were administered. The patient also received hyperbaric oxygen therapy. Thirteen days after the admittance, the infection was defeated and we could start the surgical cover. To cover the scrotal wound we have used split-thickness skin grafts taken from the right thigh. These grafts took at 100% and the patient was discharged seven days after surgical operations. Follow-up at six months and at one year showed any functional limitation and a good aesthetic result.