Nicolò Scuderi

Surgical Management of Perianal Giant Condyloma Acuminatum (Buschke-Löwenstein Tumor) Report of Three Cases

Giant condyloma acuminatum (GCA) is a slow-growing, large, cauliflower-like tumor located in the anogenital region. This tumor has a locally destructive behavior, a high recurrence rate and occasional transformation to squamous cell carcinoma. Risk factors include anoreceptive intercourse, HIV and immunosuppression. There is no general agreement on the choice of treatment for this tumor. Wide radical excision with plastic reconstruction of skin defects seems to be the best treatment, while adjuvant therapies, such as radiotherapy and immunotherapy, may achieve good results, but their effectiveness is still uncertain. Loop colostomy, considered mandatory by several authors in order to minimize wound contamination risk, does not appear to be necessary (except in cases of anal canal involvement beyond the dentate line) if a combination of bowel cleansing, non-fiber diet and loperamide can be administered. The authors report 3 cases of perianal GCA treated by radical local excision and reconstruction by S-plasty grafts, without performing loop colostomy.

Ten years of experience in chronic ulcers and malignant transformation

Malignant degeneration of wounds is rare and often misdiagnosed. Delay in diagnosis may result in a worse prognosis. The aim of this study is to determine the number of skin cancers associated with chronic skin ulcers in our facility over a period of 10 years. Between January 2002 and December 2012, a total of about 1000 patients had consulted with us for chronic wounds, especially of vascular, diabetic and traumatic origin and pressure ulcers. Thirteen skin cancers had been detected: seven squamous cell and five basal cell carcinomas and one melanoma. We highlight how important it is to be aware of the signs suggesting a malignant change and the importance of biopsy at regular intervals during the life cycle of any chronic wound.

Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: A perspective randomised study

INTRODUCTIONnCarpal tunnel decompression with division of the transverse carpal ligament has been a highly successful procedure for the treatment of carpal tunnel syndrome. The standard longitudinal incision technique, with a long curvilinear incision, has been the optimal treatment procedure for surgical decompression of the median nerve, for many surgeons. The aim of this study was to compare the traditional open carpal tunnel release (TOCTR) technique with the minimal-access carpal tunnel release (MACTR) technique for the treatment of carpal tunnel syndrome (CTS), presenting our experience.nnnMATERIALS AND METHODSnA total of 120 patients eligible for carpal tunnel decompression were recruited into the study. The patients were randomised for treatment allocation, at a 1:1 ratio, resulting in 60 patients in group A, treated by standard TOCTR, and 60 patients in group B, treated by MACTR. To evaluate patients outcomes we used the Boston Carpal Tunnel (BCT) questionnaire; the formed scar was evaluated according to the Vancouver scale and short- and long-term complications. Statistical analysis was performed by the chi-squared test and analysis of variance (ANOVA); Excel was the program used.nnnRESULTSnIn our series, there was no complication related to the surgical intervention of any injury to nerve, artery or tendon structures. In each section of the BCT questionnaire, patients in group B had significantly better results than patients in group A at both 6 and 12 months follow-up (p < 0.001). For the Vancouver scar scale, there was a significant difference between two groups scores; group B patients had significant improvements compared with group A patients.nnnCONCLUSIONSnIn our perspective randomised study, MACTR showed statistically significant improvement compared to TOCTR. The patient tolerance is reasonably high and the procedure is compatible with the current minimal invasive trend in surgery.

Surgical Correction of Gynecomastia in Thin Patients

BackgroundGynecomastia refers to a benign enlargement of the male breast. This article describes the authors’ method of using power-assisted liposuction and gland removal through a subareolar incision for thin patients.MethodsPower-assisted liposuction is performed for removal of fatty breast tissue in the chest area to allow skin retraction. The subareolar incision is used to remove glandular tissue from a male subject considered to be within a normal weight range but who has bilateral grade 1 or 2 gynecomastia.ResultsGynecomastia correction was successfully performed for all the patients. The average volume of aspirated fat breast was 100–200xa0ml on each side. Each breast had 5–80xa0g of breast tissue removed. At the 3-month, 6-month, and 1-year follow-up assessments, all the treated patients were satisfied with their aesthetic results.ConclusionsLiposuction has the advantages of reducing the fat tissue where necessary to allow skin retraction and of reducing the traces left by surgery. The combination of surgical excision and power-assisted lipoplasty also is a valid choice for the treatment of thin patients.

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.

A new dermal filler made of cross-linked and auto-cross-linked hyaluronic acid in the correction of facial aging defects

A novel Hyaluronic Acid (HA) derivative dermal filler has been developed with characteristics especially suited for nasolabial folds (NLF) and facial defects due to volume loss.

Extracorporeal Shock Wave Therapy: An Emerging Treatment Modality for Retracting Scars of the Hands

Prolonged and abnormal scarring after trauma, burns and surgical procedures often results in a pathologic scar. We evaluated the efficacy of unfocused shock wave treatment, alone or in combination with manual therapy, on retracting scars on the hands. Scar appearance was assessed by means of the modified Vancouver Scar Scale; functional hand mobility was evaluated using a range-of-motion scale, whereas a visual analogue score was implemented for detecting any improvements in referred pain. Additionally, biopsy specimens were collected for clinico-pathologic correlation. For each active treatment group, statistically significant improvements in modified Vancouver Scar Scale were recorded as early as five treatment sessions and confirmed 2 wk after the last treatment session. Analogous results were observed when assessing pain and range of movement. Histopathological examination revealed significant increases in dermal fibroblasts in each active treatment group, as well as in neoangiogenetic response and type-I collagen concentration.

Use of Integra® dermal substitute in the treatment of complex wounds caused by antiblastic extravasation injury

Antiblastic chemotherapy (CTA) extravasation is an accident often underestimated, unrecognised, untreated and probably not reported. It can cause necrosis of surrounding tissues with possible exposure and damage of tendons, ligaments, bones and consequent functional and aesthetic impairments. The damage amount depends on multiple factors such drug administration technique, patient condition, extravasation duration, amount and biochemical properties of escaped drug. Antiblastic drugs are ranked in necrotising (produce immediate damage, bind DNA, remain long, causing progressive tissue damage with ulceration), blistering (rapidly metabolised, causing immediate damage), irritant (cause inflammation and irritation, depending on the volume transferred), neutral (no local reactions). CTA extravasation manifests or with blister formation, defining a hardened area around the point of needle insertion (type I), or with fluid leakage in the intercellular space, often not visible on the skin (type II). Early detection is crucial. Numerous treatment modalities are described (Table 1) ‘wash-out’ e immediately after extravasation, before any antidote, fine needles are placed around and in the centre of the extravasated area and saline solution is injected subcutaneously up to a maximum of 500 ml (dextrose 5% for oxaliplatin extravasation); drug dilution e small volumes of the selected fluid are injected intra-perilesionally; ‘pin-cushion’ e 0.2e0.4 ml of antidote are instilled subcutaneously around the affected area; emergency suction; hot packing; limb elevation; i.v. dexrazoxane in extravasation of doxorubicin, epirubicin and GM-CSF; fractionated/low molecular weight heparin subcutaneous administration; necrotic area excision followed by VAC therapy and/or skin graft or flap coverage.

Evaluation of a new hyaluronic acid dermal filler for volume restoration

Objectives: The present study aimed to evaluate the effectiveness and safety of hyaluronic acid gel for the treatment of volume loss or contour deficiency. Methods: This 6-month, open-label study recruited sixty adults aged 40–65 years with bilateral moderate to severe volume loss or contour deficiency (Facial Volume Loss Scale [FVLS] score: 2–5). Eligible subjects were treated at the baseline visit with an injection of hyaluronic acid gel in one or more of three facial subregions: the zygomatic malar region, the anteromedial cheek and nasolabial folds. Results: A significant improvement from baseline was observed in the FVLS score at each study visit up to 6 months post treatment (p < 0.0125 by Wilcoxon test). A significant improvement was also observed in the Global Aesthetic Improvement Scale (GAIS) at each visit up to 6 months. The study showed that the GAIS score improved in 100% of subjects at month 3, while at the end of the study (month 6) the percentage of improved subjects decreased to 91. Treatment effect was maintained by 100% of subjects up to month 3, while 57% of subjects showed a persistence of effect up to month 6. Conclusions: Volume loss or contour deficiency may be safely and effectively corrected using the new dermal filler.

Skin ulcer caused by venous extravasation of heroin

The accidental leakage of the compound, in this case heroin, from the veins where it is injected, causes the formation of tissue lesions. Similar mechanisms lead to progressive tissue necrosis, which, if not immediately treated, results in the loss of the relevant function. A 57‐year‐old man presented a skin lesion on the posterior region of the left forearm with extensive necrosis of skin and subcutaneous layer involving the underlying muscle planes, caused by a venous extravasation of heroin that he reports having injected himself. The wound size is 15 × 10 cm; it had a sanious, fibrinous, secreting and smelly bottom. In this period, the patient was subjected to daily focused dressing before debridement of the lesion through a collagenase plus hyaluronic acid ointment: Bionect Start®; (FIDIA Pharmaceutical, Abano, Italy). The therapeutic choice was rewarded with a complete resolution of the wound through a non‐invasive technique and over a short period. Avoiding the hospitalisation of the patient achieved a reduction of risks for him and of the costs for the National Health Service (NHS). The Bionect Start®; (FIDIA Pharmaceutical) as well as allowing the healing of the wound also decreased significantly the pain felt by the patient, the amount of exudate and the bad smell improving in a non‐negligible way his quality of life.