Enrico Zingarelli

Patient's pain feedback using negative pressure wound therapy with foam and gauze.

Wounds can be caused by different mechanisms and have a significant morbidity and mortality. Negative pressure wound therapy (NPWT) is one of the most successful treatment modalities for wound healing. We have been using both foam and gauze‐based NPWT. During application of NPWT, we noticed that the patients pain was of varying intensity depending on the filler used. The aim of our work was to compare the level of pain and feedback before, during the treatment and at the dressing change after treatment with NPWT with two different fillers. For this study, we compared a pool of 13 gauze‐treated patients with a pool of 18 foam‐treated patients regarding the level of pain and feedback before, during the treatment and at the dressing change after treatment with NPWT. They were all post‐traumatic patients with loss of tissue up to the muscular band. The patients were asked to respond to a questionnaire interviewed by the same physician to assess the level of pain using VNS (verbal numerical scale). We observed similar difference of means before and during the treatment with NPWT with gauze and foam. Regarding the pain at the dressing change, the mean of the scores for the foam was 6·5 while for the gauze was 4·15. In this case, we noticed the most significant difference between means from the scores given: 2·35 which was a statistically significant difference between the two groups (P = 0·046). The finding of this study confirms less pain at the dressing change after treatment with gauze‐based NPWT. In our opinion, this finding is related to the more adhesive property of the foam probably because of the ingrowth of the granulation tissue in the micropores present on the foam. Considering this statement, we recommend the foam for neuropathic and paraplegic patients and the gauze for patients with bone and tendon exposition wounds, patients that do not tolerate NPWT with foam and low compliant patient particularly paediatric and old‐age patients. We remind that the performance of this study was not sponsored by any company.

Treatment of chronic heel osteomyelitis in vasculopathic patients. Can the combined use of Integra®, skin graft and negative pressure wound therapy be considered a valid therapeutic approach after partial tangential calcanectomy?

Osteomyelitis of the calcaneus is a difficult problem to manage. Patients affected by osteomyelitis of the calcaneus often have a below‐the‐knee amputation because of their comorbidity. In this article, we present seven cases of heel ulcerations with chronic osteomyelitis treated with Integra® Dermal Regeneration Template, skin graft and negative pressure wound therapy after partial tangential calcanectomy, discussing the surgical and functional results. In this casuistic of patients, all wounds healed after skin grating of the neodermis generated by Integra®, with no patient requiring a below‐knee amputation.

Gauze-based negative pressure wound therapy: a valid method to manage pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon ulcerative, non‐infective chronic inflammatory skin disorder of unknown aetiology. Systemic therapies are necessary to control the associated medical diseases, and, due to the inflammatory nature of PG, topical or systemic immunosuppressant agents are effective, but wound healing is usually slow. Negative wound pressure therapy (NPWT) has become an important tool for the management of complex skin ulcers, and usage in PG has been recently described in the literature: we present four cases of classic PG in which NPWT in association with systemic therapy achieved wound healing and a drastic pain reduction.

Surgical debridement with VERSAJET: an analysis of bacteria load of the wound bed pre- and post-treatment and skin graft taken. A preliminary pilot study

Surgical debridement, which is used for the removal of necrotic tissue from a wound, is becoming more and more important in the treatment of skin injuries. VERSAJET (VERSAJET™, Versajet Hydrosurgery System, Smith and Nephew, Hull, UK) is one of the techniques used for wound debridement. Medical literature does not present either analytical or comparative data correlating the bacterial load with the VERSAJET treatment. For this reason, we have decided to carry out a study to evaluate the level of bacterial contamination before and after the surgical debridement treatment with VERSAJET and, in connection with this, the correlation between the bacterial load and the successful healing of the skin graft. We took a total of 100 bacteriological swabs, 50 before and 50 from 27 selected patients after the treatment with VERSAJET, with which the wound bed was prepared to receive the skin graft or Integra graft in order to acquire data about the level of bacterial contamination. After analysing all those data we can assume that reducing the bacterial load is not the only variable which the successful healing of the skin graft depends on. In conclusion, there is still many data to analyse and study in order to better understand the qualitative and quantitative presence of bacteria and the success of this future surgical procedure. We remind that the performance of this study was not sponsored by any company.

Electrical stimulation for difficult wounds: only an alternative procedure?

In the wound healing research, the exact mechanism of action of different modalities of electrical stimulation (ES) remains controversial and unresolved. In this study we discuss a particular ES, with a different type of waveform, corresponding to the principle of stochastic resonance. Between July 2008 and May 2010, 32 patients were enrolled and ES was applied to wounds using the bioelectrical signal therapy (BST) device (LifeWave, Petach Tiqwa, Israel). The outcome evaluated in group 1 (n = 21) was wound healing, while group 2 (n = 11) was evaluated for wound‐related pain [Visual Number Scale (VNS) pain scale] during treatment. In group 1, 87% of the wounds closed in an average time of 97 days (range 10–150 days); three patients were lost to follow‐up. In group 2, 45% of the patients experienced a complete pain disappearance after 7 days of treatment; 36% reported a reduction in VNS from 9·3 to 3·2 in 7 days; 19% stopped morphine‐like painkillers after 2 weeks. The clinical application of the stochastic resonance enables the usage of easy‐to‐use, non‐invasive, painless and pain‐relief treatment. Our experience with ES has demonstrated the BST device to be a very good alternative in cases of small size defects, compared with other therapies such as surgery, dressing and negative pressure devices.

Preoperative color duplex echographical venous mapping before autologous fat graft for calf augmentation: a case report of superficial vein thrombosis and prevalence of intersaphenic anastomosis.

AbstractAutologous fat grafting for calf augmentation is considered an easy and safe technique. Only few cases of potential complications have been described in literature; among them, vein thrombosis was never reported. We report a case of superficial vein thrombosis of the intersaphenic anastomosis after fat graft for calf symmetrization in club-foot syndrome. A color duplex echographical study showed that such intersaphenic anastomoses are present in all patients, but they have an ectatic diameter in 70% of patients with great saphenous vein insufficiency and in 50% of patients without insufficiency. The plastic surgeon should be aware of the presence and topography of such anatomical variations before performing the procedure. Moreover, a preoperative color duplex echographical venous mapping may help the surgeon in avoiding the trauma on vein variants and subsequent complications.

Fascio-cutaneous flaps for chest wall reconstruction after massive inflammatory breast cancer: a case series

BackgroundInflammatory breast cancer represents a rare condition that presents poor prognosis with high risk of recurrences and greatly affects patients’ quality of life. The resective surgical treatment frequently requires challenging reconstructive solutions to restore a proper tissue layer for the chest wall. Reconstructive methods are nowadays still matter of debate.MethodsA retrospective review of all cases of massive inflammatory breast cancer that underwent mastectomy and reconstruction with fasciocutaneous flaps from October 2009 to September 2014 was performed at our department. Patient demographics, indications, flap specifics, complications, and number of operations were collected.ResultsOur review identified five cases. A lateral thoracic flap was planned in two cases, a modified lateral thoraco-dorsal flap in one case, a combination of scapular and pubic flaps in other case, and a thoraco-epigastric and lateral thoracic flap association in the remaining case. The mean patient age was 60 years (range, 35 to 76 years). Flap dimensions ranged from 9cm to 14 cm in width and 20 to 24 cm in length. Partial necrosis of the flap distal part occurred in two cases requiring minor flap revision.ConclusionsResective surgical treatment of inflammatory breast cancer might require a challenging reconstructive planning. In this scenario, fasciocutaneous flaps are an interesting option due to their versatility, easiness of harvesting, low morbidity, and complications rate.Level of Evidence: Level IV, therapeutic study.

Redefinition of Nasal Alar Rim After Dog Bite

A36-year old male patient presented with a distortion of the right nasal alar rim due to second intention healing after a dog bite occurred 10 years ago (Figure 1). The cicatricial alar margin retraction and the resulted asymmetry caused him subjective psychological discomfort and difficulties in social life especially in the relationship with his young sons. He presented at the authors’ department with the aim of restoring nasal natural aspect, with the request to minimize the extent of facial scars. How would you reconstruct this defect?