Massimiliano Tripoli

Different Surgical Approaches to Treat Chronic Tophaceous Gout in the Hand: Our Experience

Chronic tophaceous gout is a disabling erosive arthritis characterized by an elevated serum urate concentration, recurrent attacks of arthritis, and deposits of monosodium urate crystals in synovial fluids. Tophi, ulcerations of the overlying skin, and fissures of the interarticular cartilage may occur in advanced stages, combined with deformities of the joints and decreased active joint flexion and extension. Although the timely use of allopurinol is associated with a decrease in the frequency of deposits of the tophaceous substance, however, surgical management is necessary to restore and improve the cosmesis and joint function, to alleviate symptomatic discomfort, and to reduce the risk of infection when the overlying skin becomes ulcerated. The authors present their experience in the surgical management of the chronic tophaceous gout in the hand.

The "Jacobsen flap" technique: a safe, simple surgical procedure to treat Dupuytren disease of the little finger in advanced stage.

The surgery for advanced stages of Dupuytren disease of the little finger is controversial. In the literature, several techniques have been described with variable reported results and postoperative complications. Percutaneous needle fasciotomy, McCash technique, and dermofasciectomy are often performed for surgical treatment but they present significant complications and limits. This study reviews our experience of using the Jacobsen flap technique, a modification of the McCash procedure. We found that the Jacobsen flap technique for the significant correction of the contracture, the low rate of complications, and the relatively simple surgical approach is an excellent alternative to percutaneous needle fasciotomy, dermofasciectomy, or amputation.

Basal Cell Carcinoma Arisen on Rhinophyma: Report of Four Cases

Rhinophyma is characterized by progressive hyperplasia of nasal sebaceous glands, with fibrosis, follicular plugging and telangiectasias. The term “rhynophyma” derives from the Greek words rhino (meaning nose) and phyma (meaning growth). It is considered the final stage of acne rosacea. Though rare in occurrence, malignant tumors can grow over rhinophymatous skin, with basal cell carcinoma (BCC) being the most commonly reported tumor. Although a rare event, the development of BCC should always be sought in presence of rhinophyma, and also small changes of the skin lesion characteristic that it represent. We report four cases of BCC arising on rhinophyma observed between 1998 and 2012. We recommend the need for a histologic examination of the suspicious lesions or all surgically removed tissue in patients with rhinophyma.

Retrospective analysis in lower limb reconstruction : propeller perforator flaps versus free flaps

Background Technical advancements and increasing experience in the management of soft tissue defects in lower extremities have led to the evolution of decisional reconstructive algorithms. Both propeller perforator flaps (PPFs) and free flaps (FFs) proved to be useful methods of reconstruction for lower extremities defects, offering alternative reconstructive tools. We present a case series of PPFs and FFs for reconstruction of lower limbs defects, analyzing and comparing treatment and outcomes. Methods Through a retrospective analysis, we report our experience in performing PPFs or FFs for reconstruction of soft tissue defects of the lower extremities, in patients admitted between 2010 and 2015 at the Department of Plastic and Reconstructive Surgery, University of Palermo. In these patients, we evaluated location and causes of defects, types of flaps used, recipient vessels, complications, time to healing, and aesthetic outcome. Results A primary healing rate was obtained in 13 patients for PPF and 16 cases for FF. Revision surgery for partial skin necrosis was required in eight cases (PPF: four and FF: four). Recovery time and hospitalization period were eventually shorter in patients with FFs, due to lower rate of complications and revision surgery. Conclusion In the past years, our indications for reconstruction with PPFs in the lower limb have become more restricted, while we favor reconstruction with FFs. Recommendations are provided to orient surgical treatment in small, medium, and large lower limb defects.

Update on the role of molecular factors and fibroblasts in the pathogenesis of Dupuytren’s disease

The mechanism by which the fibroblast is able to trigger palmar fibromatosis is still not yet fully understood. It would appear certain that the “abnormal” fibroblasts continuously synthesise profibrotic cytokines which are able to determine the activation to myofibroblasts, to stimulate them to the further proliferation and synthesis of other cytokines, to modify the cells’ differentiation and ultrastructural characteristics, as well as the production of matrix and other proteins. Several fibroblast growth factors have been suggested to be responsible of an abnormal cell activation with an aberrantly elevated collagen synthesis and extracellular deposition in Dupuytren’s disease, as TGF-Beta, TNF-Alfa, PDGF, GM-CSF, free radicals, metalloproteinases, sex hormones, gene modified expression, mechanical stimulation. The Authors review the current state of knowledge in the field, by analyzing the role of these cytokines in the palmar fibromatosis.

Characteristics, Management Techniques, and Outcomes of the Most Common Soft-Tissue Hand Tumors: A Literature Review and Our Experience

Introduction Diagnosis of the hands soft-tissue tumors is often difficult because of the different anatomic structures present in this region and yet clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. Materials and Methods At the Department of Plastic and Reconstructive Surgery at the University of Palermo, 629 patients with hand tumors were studied. Treatment was surgical for all of them; also radiotherapy and chemotherapy were necessary based on the histological diagnosis. Conclusions Our retrospective study with a literature review aims to present the most commonly observed soft-tissue hand lesions, analyzing their causes, their objective and instrumental evaluation, and their treatments.

A Rare Case of Giant Basal Cell Carcinoma of the Abdominal Wall: Excision and Immediate Reconstruction with a Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Flap

Patient: Female, 82 Final Diagnosis: Giant basal cell carcinoma Symptoms: Anemia Medication: — Clinical Procedure: — Specialty: Plastic Surgery Objective: Rare disease Background: Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. Case Report: We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. Conclusions: Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.

Basal cell carcinoma on rhinophyma: a case series analysis

BackgroundSeveral authors described the presence of malignant tumors that rarely can grow hidden over rhinophymatous skin. Basal cell carcinoma (BCC) is the most commonly reported tumor and it should always be sought and diagnosed in presence of a rhinophyma.MethodsBetween 1998 and 2012, 56 cases of rhinophyma were treated at our department. There were 54 males and 2 females with an age range between 34 to 87 years. In all cases of major or moderate degree, scalpel decortications was executed, while in cases of suspicious lesions, a biopsy and histological examination was also indicated.ResultsIn this series, six cases of BCC were diagnosed and treated showing an incidence rate higher than 10 %.ConclusionsOur results support the need of histological examination of the surgically removed tissue in patients with rhinophyma.Level of Evidence: Level IV, therapeutic study.

The “Jacobsen Flap” for the Treatment of Stage III–IV Dupuytren’s Disease at Little Finger: Our Review of 123 Cases

For selective fasciectomy in patients with Dupuytren’s disease at Tubiana Stage I–II, midline longitudinal incisions with serial Z-plasties, Bruner zigzag incisions, and V-Y plasties over the palm and most severely affected fingers are accepted methods. Advantages of these approaches are good intraoperative visualization of the fibrous tissue, rapid dissection, minor tissue trauma, and usually the possibility of a tension-free wound closure (Brenner and Rayan 2003). In cases of Dupuytren’s disease at Stage III and IV, with severe digital flexion, inelastic overlying skin, and expected skin shortage after contracture release, these incisions may sometimes be useful, but in our experience, quite often are insufficient, since they may increase the risk of edema, skin necrosis, and wound breakdown. In these cases, dermofasciectomy with full-thickness skin grafting and the McCash technique (McCash 1964) are more often performed (Brenner and Rayan 2003), with different rates of complications and recurrence (Lubahn 1996, 1999).