Michele Maruccia

Treatment of Post Mastectomy Pain Syndrome after mastopexy with botulinum toxin

Post Mastectomy Pain Syndrome (PMPS) is a chronic pain condition, persisting formore than threemonths after breast surgery. Pain can result from any surgical procedure, but this syndrome is more commonly associated with radical mastectomy with axillary lymphadenectomy. The etiopathogenesis is not clear but the pain is typically neuropathic in nature, characterized as a dull, burning, and aching sensation exacerbated by movements of the shoulder girdle. The incidence is high, ranging from 20 to 50%. This chronic pain causes significant anxiety to the patient and can invoke frustration in the treating practitioner when an obvious cause and a curative therapy can not be found. Described therapies are conventional analgesia, non-pharmaceutical treatments such as physiotherapy, homeopathy, reflexology, reiki, acupuncture and massage, or combined therapies. Women described these therapies as being helpful for ‘dealing with’ the pain, and described creating their own strategies for how best to live with chronic pain. We observed a complex case of PMPS after mastopexy in which an effective treatment was achieved with botulinum toxin infiltration. The pain was localized in the central quadrant of the left breast, persisting continuously for 3 months after surgery; with time, it tended to become more severe, radiating to the whole breast, being described as numbness, pins and burning sensations. The patient could not wear a bra or tight-fitting clothing or raise her arms to not exacerbate the pain. At physical examination, the Tinel’s sign was positive (Figure 1). Different pain killers were administrated (opioids, pregabalin, paracetamol, tramadole), allowing only a symptomatic control of the pain. Then, an anterior intercostal nerve block was performed with lidocaine 2%, obtaining pain relief for 10 days. Also a lipofilling was performed to correct a slight breast asymmetry, but it did not resolve the pain syndrome. Therefore, botulinum toxin A (BTX-A) percutaneous infiltration was proposed to the patient; it represented an off-label indication, already described for the treatment of chronic pain syndrome, and the patient fully consented to it. Furthermore, over the past two decades, the use of botulinum toxins in clinical medicine significantly improved management of many disorders, (i.e. spastic and autonomic over-activity syndromes). BTX-A percutaneous infiltration was performed under anterior intercostal nerves block with 10 cc of lidocaine 2% for each side. A dilution of 4 ml of normal saline per 100 units of BTX-A (Botox , Allergan, Inc., Irvine, CA, USA) was used to prepare a solution of 2.5 U/0.1 ml. The infiltrated area extended to the entire pectoralis major muscle, divided into 20 sectors. BTX-A was injected using a graduated 1-ml syringe with a 27-gauge 2 inches needle, inserted tangentially into the skin surface; each sector was infiltrated with 0.1 ml of solution, for a total quantity of 50 units for each breast. After treatment, the patient referred pain relief, allowing the rapid suspension of analgesic therapy. Three days after infiltration, the patient did no longer feel pain, she was able to lift and rotate the arm and Tinel’s sign was negative. No recurrence of the pain syndrome was observed in the following 9 months during which the patient could wear a bra, touch her breasts, lift her arms, returning to a normal personal and professional life (Figure 2). The effect of botulinum toxin is transitory (approximately 6 months) and in case of PMPS recrudescence, BTX-A infiltration can be repeated. Also, this treatment is fast, simple, well tolerated and without major complications. In conclusions, PMPS therapies are palliative or transient strategies. Our observation highlights that BTX-A infiltration is a safe and effective treatment of PMPS; on the basis of our experience and on other studies, we presume that it depends on the analgesic, anti-inflammatory and antispastic effects of BTX molecule.

Necrosis of the columella associated with nasal continuous positive airway pressure in a preterm infant.

Dear Editors, We present a case of nasal injury secondary to nasal continuous positive airway pressure in a 28-week-preterm infant, hospitalised in the neonatal intensive care unit of our hospital. After having applied a nasal continuous positive airway pressure (NCPAP) device at 4 weeks of birth, the infant showed a loss of cutaneous substance at the level of nasal columella with partial exposure of the underlying cartilaginous structures (Figure 1). NCPAP is a non-invasive form of ventilation that is becoming increasingly popular as a method of respiratory support in the newborn and, more recently, as a primary mode of respiratory support for preterm infants with respiratory insufficiency (1). In our patient, the use of the NCPAP device was absolutely necessary: when we moved it away from the nares of the infant, there was a sudden decrease in PO2. One of the complications of NCPAP application is nasal injury, ranging from oedema to columella necrosis, which may occur with all types of nasal prongs and NCPAP devices (24). The major underlying mechanism of nasal injury related to NCPAP appears to be the pressure generated on the columella by the prongs. Current available interfaces are too rigid, oversized or too heavy for smaller infants. Increased pressure on the columella causes diminished circulation of blood flow. This subsequently impairs tissue perfusion and leads to ischaemia along with tissue damage. Persistent erythema, dermal injury, oedema, induration and finally an ulcer can

The use of negative pressure therapy and hyaluronic acid for the management of post-traumatic lower limb injury.

Management of severe limb trauma continues to challenge surgeons. Suitable treatment should be individualised for each patient, taking into consideration not only the wound extremity but also the associated injuries, age and socioeconomic status of the patient with the goal to recover function and to improve patient quality of life. The aim of this report is to present a severe degloving multiplane lower limb injury case in which a conservative treatment of the wound was performed with negative pressure therapy and dermal substitute, avoiding amputation and restoring limb function.

Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: A case series

The anterolateral thigh flap is a workforce flap in reconstructive surgery, however, variations in it is vascular anatomy are not uncommon. These variations may affect flap design and survival, especially when large flaps are required. In some anatomical variants the anterolateral thigh flap is supplied by two separate dominant pedicles, and in these cases a bi‐pedicle modification may be necessary to ensure complete flap viability. The aim of this report is to evaluate the outcomes, and present our approach in using bi‐pedicle anterolateral thigh flaps as a method to reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects.

A rare case of lymphangioma in the gluteal region: surgical treatment combined with sclerotherapy and laser therapy.

BackgroundLymphangioma, a rare benign malformation of lymphatic channels, is among the surgically treatable diseases of the lymphatic vessels. However, damage to surrounding structures together with incomplete resection due to adjacent organ infiltration and a high recurrence rate have encouraged the search for alternative treatments. This study aimed to identify the best therapeutic management for this difficult-to-treat disease.MethodsThis report describes a case of congenital lymphangioma in the gluteal region in a young woman. First, sclerotherapy of the lymphangioma was performed and then surgical excision of residual lesions. Finally, as a third therapeutic step, the patient also was subjected to a cycle of laser therapy with the aim of further improving the appearance of the gluteal region. Pulsed dye laser was used to remove cutaneous dyschromias, and an erbium:yttrium–aluminum-garnet laser was used to remove surface irregularities and obtain better skin smoothness. The outcome assessments included standardized photography, the physician’s global assessment, the patient’s satisfaction scores, and magnetic resonance imaging of the gluteal region.ResultsAll the lesions of lymphangioma were removed. After the last laser treatment, the skin of the entire treated region was eutrophic and uniform in color, and it appeared to be smooth and soft when palpated. The patient was satisfied with the clinical and aesthetic results achieved.ConclusionsThe combination of sclerotherapy with surgery can be a good solution for the treatment of lymphangioma. The authors also propose laser therapy as an additional therapeutic approach that may follow surgery or sclerotherapy with the aim of improving the skin trophism and the appearance of the affected region.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Suprafascial versus traditional harvesting technique for free antero lateral thigh flap: A case‐control study to assess the best functional and aesthetic result in extremity reconstruction

Clinical applications of ALT flap have currently extended to extremity (hand and foot) as well as oral cavity reconstruction. In these anatomical areas, the traditional harvesting technique presents a few disadvantages such as bulkiness of the recipient site and potential donor site morbidity including damage to the deep fascia and skin graft adhesions. The purpose of the present study was to compare the functional and aesthetic outcomes of upper and lower extremity reconstruction with either suprafascial or subfascial harvested anterolateral (ALT) flaps.

Flap monitoring with continuous oxygen partial tension measurement in breast reconstructive surgery: A preliminary report

The best method for the postoperative monitoring of flaps in reconstructive surgery is still a matter of debate. The aim of this study is to evaluate the usefulness of an oxygen partial tension monitoring system for the postoperative follow‐up of a series of breast flaps, in addition to the traditional periodical clinical evaluations.

The pineapple technique for excision of large plexiform neurofibromas

Plexiform neurofibromas (PNF) occur in up to 30% of patients with neurofibromatosis type 1 (NF1). To date, management of this tumors remains medically challenging. Surgical approach represents the only viable treatment option of progressive growing plexiform neurofibromas but surgical complications may be relatively common. Intraoperative tumor bleeding was found to occur as one of the most frequent complications. We report the case of a 28-year-old male patient presented with a large back-pack shaped plexiform neurofibroma. The tumor was successfully excised using the pineapple technique, with minimal intraoperative blood loss. To our opinion, this is the first reported case of excision of a plexiform neurofibroma combined with multi-layered hemostatic suture technique. This novel application proves the efficacy and the potential of the technique, extending its feasibility to the excision of any type of vascular tumor or extensive cancerous masses.Level of Evidence: Level V, therapeutic study

Complications of the Kirschner wire cover

Dear Editors, We would like to report our experience about the complications related to use of Kirschner wire (K-wire) and the best way to dress it. Transcutaneous devices are commonly used to stabilise fractures, to correct and to provide stability to small bone fractures. One of the main problems is the potential for pin-site or pin-tract infection, leading to osteomyelitis. Pin tract is a chronic wound containing a foreign body providing an ideal focus for bacterial colonisation. Infection rates range between 0·5% and 30% (1). Pin-tract infections can decrease

Reconstruction of posterior auricular ear surface defects: “Ear Keystone graft”

Drinking is one of the most common human activities and our findings suggest there are gender specific drinking patterns related to development of perioral wrinkles. Women ‘pucker’ and men are ‘tight lipped’. Twenty-one (70%) of 30 women, of whom 13 (43.3%) had a WS >30 but <90 and 9 (30%) with a ‘severe’ score, typically made their lips pucker whilst drinking from a glass, causing orbicularis oris muscle to contract in a ‘J’ shaped, sphincteric pattern, promoting wrinkle formation. In comparison, twenty-four (80%) of 30 men, of whom 12 (40%) with ‘mild’ score and 16 (53.3%) with ‘moderate’ score, tended to keep their upper lip taught whilst drinking. Each time thepuckering action of orbicularis oris is used, a groove forms beneath the surface of the skin and, as skin ages, it loses its flexibility and is no longer able to spring back in place and collagen fractures appear. These grooves become permanent features. In this context, it is interesting also to note that the orbicularis oris muscle is anchored 1.5 times closer to the dermis in women than in men and the fibrous connections between the muscle and the dermis can cause an inward traction, thereby creating deeperwrinkles. The structural gender differences could play an important role in perioral wrinkle formation and our observation that women tend to use a different pattern of orbicularis oris action indrinking, oneof themost frequentdaily activities, is a likely explanation of why perioral wrinkles are more common and more severe in women and contribute to improve our understanding of wrinkle formation.