Paola Parisi

Optimal care for eyelid contraction after radiotherapy: case report and literature review.

Radiotherapy represents a major problem in facial surgery. Orbital and periorbital radiation therapy causes a contraction of the soft tissues. Scarring with ectropion is the most severe complication, with shrinking of the anterior lamella, skin dystrophy, muscle atrophy, and alteration of the remaining soft tissues. Goals for reconstruction include correction of distorted orbitofacial tissues and the restoration of orbital structures. The management of these patients is not standardized. We suggest systematically using a combined approach of surgery and lipofilling to restore the orbital deformity and dystrophy, respectively. For this purpose, we present the case of a 65-year-old woman with asymmetry of the orbital regions and severe lower eyelid cicatricial ectropion due to multiple radiation treatments in childhood for an extensive cavernous hemangioma of the right side of the face. We performed a reconstructive procedure using a tarsal strip technique in association with contralateral upper eyelid graft to correct the extensive retraction of the right lower eyelid and lid asymmetry. Subsequently, the patient underwent lipofilling to correct the post-radiotherapy dystrophy. Skin texture, softness, and elasticity greatly improved with further symmetrization. The combined treatment with surgery and lipofilling can significantly improve the functional and cosmetic outcome of shortened and dystrophic eyelids with a successful result with regard to post-radiotherapy retraction.

The effectiveness of negative pressure therapy on infected wounds: preliminary results

Vacuum‐assisted closure (VAC) therapy is a sophisticated system that maintains a closed, humid, sterile and isolated environment. Wound infection is considered a relative contraindication. The objective of this study is to extend the indications for VAC therapy to include infected wounds by demonstrating its ability to increase the antibiotic concentration in the damaged and infected tissues. Patients who presented with ulcers infected with daptomycin‐sensitive bacteria were eligible to be enrolled in this prospective study. They were given antibiotic therapy with daptomycin with a specific protocol. A biopsy of the lesion was carried out to detect tissue concentration of the drug at time 0. Afterwards, the patients were subjected to VAC therapy. At the end of VAC therapy, a second lesion biopsy was performed and analysed to detect tissue concentration of the drug at time 1. A control group was enrolled in which patients followed the same protocol, but they were treated with traditional dressings. Fishers exact test was used to compare the two groups. The results highlighted a significant increase in the concentration of antibiotics in the study group tissue; the improvement was sensibly lower in the control group. Statistical differences were not found between the two groups. The preliminary analysis of the data showed an important increase of antibiotic concentration in the tissue after VAC therapy. Despite the encouraging data, it is necessary to broaden the sample of patients and perform the same study with other antibiotics.

Retention of polyurethane foam fragments during VAC therapy: a complication to be considered

Vacuum‐assisted closure (VAC) therapy is a closed‐loop, non‐invasive active system, characterised by a controlled and localised negative pressure applied on porous polyurethane absorbent foams. It promotes healing of acute and chronic wounds. Therapeutic effects of VAC therapy have been proved and demonstrated; however, this method can have some disadvantages. Even if it is a quite versatile device, only qualified medical/paramedical personnel should use it in order to avoid possible complications that can occur after an improper application. In this report, 11 cases of foam‐fragment retention within the wound are presented. This rare complication did not promote healing, but further hindered it. On the basis of our experience, it is mandatory to define the indications, benefits and limitations of VAC therapy.

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.

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction.

BACKGROUND Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. METHODS Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. RESULTS Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. CONCLUSIONS As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

A horizontal V-Y advancement lower eyelid flap: our experience performing a bilateral suspension to the periosteum.

tific basis; thus, the evidence level is none. The authors also mention the complications of polyacrylamide gel in women who were treated with polyacrylamide gel injections for breast augmentation in Ukraine.3 Again, the citation does not apply to our study because the injected polyacrylamide gel was not the same as that used in our population (Aquamid; Contura International A/S, Soeborg, Denmark), the anatomical region is not comparable (breast tissue versus face), the indications are different (breast augmentation versus human immunodeficiency virus–related lipodystrophy), and the volumes injected were much larger (mean, 230 ml versus 7 ml). The second case reported by Wang et al. describes a patient who was continuously treated with polyacrylamide gel for 8 years and who developed facial ulcers and infection. The skin ulcers and scars shown in Figure 1 could have been caused by an inadequate injective technique (too superficial an injection), excessive volume of injected material per cubic millimeter (repeated injections for 8 years are certainly suspicious), inadequate filler (not all polyacrylamide gels are the same), inadequate patient behavior and, in some cases, injection in areas different from those used in patients with human immunodeficiency virus–related lipodystrophy. More information should be provided to correctly interpret this case report. Finally, Dr. Wang presents a case of the deleterious effects of golden threads. Golden threads are not used for human immunodeficiency virus lipodystrophy; therefore, the example has no relevance to our case. Regarding the necessity of a follow-up longer than 5 years, it should be noted that in our series, 5 years was the minimal duration of follow-up, with some patients being followed for up to 6.85 years, the longest follow-up reported in the literature to date. The previously described complications of polyacrylamide gel (localized accumulation, material migration, and infection) had a low incidence in our study where a correct injective technique and careful avoidance of contamination were meticulously followed. Side effects of fillers should certainly be monitored carefully, with well-designed (if possible, blind and randomized) studies. Conversely, unsubstantiated hypotheses based on case reports will only create untoward panic in a community of already fragile patients. DOI: 10.1097/PRS.0b013e318254b639

Giant congenital nevus associated with papillary thyroid cancer: the first case report

Giant congenital melanocytic nevus is defined as a benign nevomelanocytic proliferation that is present from birth and measures ‡20 cm in diameter in adults. It is reported to occur at a frequency of one in 20,000. This pathology is usually seen in females (female : male ratio, 2 : 1) and is usually located on the back or symmetrically at the extremities. Giant congenital nevus (GCN) is associated with several other diseases, particularly with melanoma, with which its rate of coincidence is 6.3%. The literature includes a few reports of associations between thyroid disorders and nevi. We report a young woman affected by a papillary thyroid cancer coexisting with giant congenital melanocytic nevus and describe an association between the two diseases.

Superficial Leiomyosarcoma of the Glans: Report of a Case and Literature Review

Primary leiomyosarcomas of the penis are rare. Clinically and pathologically, these tumors fall into two groups: superficial and deep. Superficial lesions usually are low grade and show a limited tendency toward distant metastasis. In contrast, deep-seated tumors usually show a more aggressive behavior associated with a poor prognosis. A 62-year-old man with a superficial leiomyosarcoma of the glans penis is reported.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.