Marina Pierangeli

Paraffin oil injection in the body: An obsolete and destructive procedure

Injection of foreign materials, such as paraffin oil, is an old and obsolete procedure. The authors describe previous uses for this procedure that had been used since the 19th century and the treatment of patients affected by such a disease.

Local rh-VEGF administration enhances skin flap survival more than other types of rh-VEGF administration: a clinical, morphological and immunohistochemical study.

Abstract:  The aim of the present study was to evaluate experimentally whether administration of recombinant (rh) vascular endothelial growth factor (VEGF) can protect skin flaps from necrosis and to study the optimum mode of rh‐VEGF administration. We used rats to study the effects of local or systemic administration of rh‐VEGF on skin flap during surgery; we also tested preoperative systemic administration of rh‐VEGF to assess whether it may prepare the tissue to respond to the hypoxic injury better than previously tested methods. The animals were 30 male Sprague‐Dawley rats. Group I rats received multiple systemic injections of rh‐VEGF in the tail artery prior to flap dissection. Group II rats were injected with rh‐VEGF in the clamped left epigastric artery during flap dissection; in this group, the left flaps thus received rh‐VEGF locally (via incubation for 10 min during hypoxia) and the right flaps systemically, after blood flow restoration. Group III received saline solution instead of VEGF in the same way as group II. Skin samples from the distal portion of the flaps were collected on day 7 for morphological and immunohistochemical analysis. The flaps exhibiting the least necrosis were those treated with local rh‐VEGF, followed by those treated with systemic rh‐VEGF. The flaps that received rh‐VEGF locally showed a strong VEGF expression on keratinocytes and endothelial cells, the greatest amount of mature and newly formed vessels and strong survivin expression in endothelial cells. Local rh‐VEGF administration should thus be considered as an effective therapeutic option to enhance the survival of a tissue at risk for perfusion.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical‐related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high‐risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWTs effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re‐operation and re‐hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero‐haematoma formation and on the re‐operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Carcinoma of the Male Breast: An Underestimated Killer

&NA; Male breast carcinoma represents only 1 percent of all breast cancers. Despite the rarity of this neoplasia, the malignancy is often very aggressive, mostly because of delayed diagnosis. Consequently, large excisions are usually needed, and subsequent reconstruction is performed by means of fasciocutaneous or myocutaneous local or distant flaps, depending on the stage of the neoplasia. The signs, symptoms, prognosis, and reconstructive methods of such an unusual form of breast cancer are discussed in this article. (Plast. Reconstr. Surg. 102: 696, 1998.)

A simple and reliable method of nipple reconstruction using a spiral flap made of residual scar tissue.

Nipple reconstruction represents the final and probably the most important stage of breast reconstruction. Although several techniques have been proposed over the years to restore nipple integrity, the main problem remains the degree of shrinkage in nipple projection after reconstruction. The decrease in projection depends on the method used, even if it has been proved that every method has a degree of decrease that ranges from 50 to 70 percent. We propose a new, simple, and reliable method of nipple reconstruction in which the residual scar of mastectomy, and eventually a very small amount of healthy skin, is used in to reconstruct a neonipple. After making the preoperative measurements to center the nipple symmetrically to the opposite side, elevation of a laterally based flap is performed. The elevated skin is then twisted on its main axis, with its cutaneous part outside, and sutured in a spiral way. After that, a specific stent and dressing are applied to avoid, as much as possible, the shrinkage tendency of the neonipple. With this simple technique, we obtained fine results with a minimal residual scar. Description of the surgical technique is described in detail below.

The enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by prevena™ customizable™: Cosmetic and therapeutic results

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17–22% of health care‐associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high‐risk, clean, closed surgical incisions. The authors present a 62‐year‐old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

Profunda Femoris Artery Perforator Propeller Flap: A Valid Method to Cover Complicated Ischiatic Pressure Sores.

Summary: We report the case of a 50-year-old paraplegic man with a complicated grade III/IV ischiatic pressure sore treated with a propeller flap based on the first perforator of the profunda femoris artery. Our aim was to surgically reconstruct an ischiatic pressure sore in a patient with ankylosis using a fasciocutaneous perforator propeller flap obtained from the posterior region of the thigh. Our decision to perform a profunda femoris artery perforator propeller flap reconstruction was mainly due to the anatomical contiguity of the flap with the site of the lesion and the good quality of the skin harvested from the posterior region of the thigh. The use of the perforator fasciocutaneous flap represents a muscle-sparing technique, providing a better long-term result in surgical reconstruction. The choice of the 180-degree propeller flap was due to its ability to provide a good repair of the pressure ulcer and to pass over the ischiatic prominence in the patient in the forced decubitus position. The operatory course did not present any kind of complication. Using this reconstructive treatment, we have obtained complete coverage of the ischiatic pressure sore.

Skin expansion versus free forearm flap in forehead reconstruction.

The authors present their experience in surgical reconstruction of the forehead cosmetic unit, either with tissue expansion or free tissue transfer. Some of the cases underwent a full reconstruction of the entire cosmetic forehead unit en bloc performed by means of free forearm flap such as in postoncological exeresis and in post‐traumatic reconstruction. The other method of choice was tissue expansion. The authors expanded the forehead unit for a giant naevus treatment in a child, and used a bilateral expansion of the forehead for tumour clearance of the middle third of the forehead. Results and problems related to the two techniques are presented and discussed.

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.

Surgical Management of Pressure Ulcers

The occurrence of pressure ulcers has an important influence on the patient’s quality of life [1].