Pasquale Fino

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.

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.

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.

Intense pulsed light in the treatment of telangiectasias: case report of Behçet's disease with superficial vascular involvement.

Abstract Behçets disease (BD) is a chronic systemic inflammatory disorder of unknown etiology with variable clinical manifestations. HLA-B51 allele is the most strongly associated known genetic factor. The mucocutaneous lesions (oral aphthae, genital aphthae, skin lesions such as pseudofolliculitis) constitute the hallmark of the disease, but also gastrointestinal, vascular, central nervous systems, and others may be involved. We report a case of a young man affected with Behçets disease who presented facial telangiectasias and striae rubra in the inner region of his arms and at the level of his hips, as uncommon minor superficial vascular manifestations of BD. To manage them we have subjected the patient to a cycle of Intense Pulsed Light (IPL) therapy. Our findings showed that the use of IPL is a safe and effective treatment for telangiectasias and striae rubra, also in the complex clinical condition of Behçets disease. In fact, the treatments were well tolerated, no sign of scarring or hyper/hypopigmentation was reported and we obtained a significant improvement of the lesions in terms of color and size of them.

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.

Reconstruction after skin cancer excision through a dermal induction template: our experience.

Dermal substitutes offer alternative approaches for wounds of all thicknesses where sufficient donation sites are not available for self‐grafts. Several dermal substitutes are described in literature. This study included 20 patients treated with a dermal induction template after the removal of malignant skin cancers situated in various parts of the body. The participants were especially aged patients with multiple skin cancers, and complex clinical conditions, often affected by pathologies such as cardiopathy, diabetes mellitus, and hypercholesterolaemia, and receiving pharmacological multi‐therapies, particularly antiplatelets and anticoagulants. In many of these patients, the general complex clinical picture provided significant contraindication for complex reconstructive surgery because of the high risk involved. All patients achieved complete healing about 8u2009weeks after the first surgery. By using a dermal induction template, it was possible to cover substantial loss of substances without the need of autologous tissue, with smoother and less apparent scar, minor occurrence of hypertrophic and retracted scars, better flexibility of healed skin and therefore a better result from an aesthetic point of view.

An unusual case of multiple melanoma and non-melanoma skin cancers of the leg

Dear Editors, Skin cancers are a very common malignancy. According to American Cancer Society estimates, more than 70 000 new cases of invasive melanoma and more than 53 000 new cases of melanoma in situ will have occurred in the USA by the end of 2011 (1). However, the annual incidence of non-melanoma skin cancers, such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is more difficult to estimate. Early diagnosis and treatment provide the best chance for survival and reduced morbidity. In patients with BCC, the prognosis is relatively good, but some BCC forms, such as infiltrative and morpheaform BCC, are associated with the highest recurrence rates and greatest morbidity (2). A rare and often misdiagnosed complication is the malignant transformation of chronic ulcers of the lower limbs. In the majority of these cases, the malignancy consists of a rare, but highly aggressive SCC which has an average of three decades of latency before malignant transformation (3). We report a case of a 72-year-old woman who presented to our facility complaining of a chronic wound on the ventral lower side of the right leg. Ten years prior the patient had reported for surgical excision of a skin lesion histologically identified as melanoma. Physical examination of the right leg skin revealed a shallow ulcer of 4 × 2 cm diameter and skin lesions with mean diameter ranging 0.5–1.5 cm. The ulcer had a well-defined border and a plain wound bed appearing as granulation tissue with no necrosis (Figure 1). Signs of chronic venous insufficiency were found on both legs and feet. The patient reported that the ulcer had surfaced 3 years before. After 2 months of daily topical treatment with various dressings, including disinfection with sodium hypoclorite 0.05% (Amukine Med® 0,05%, Amuchina S.p.A.; Genova, Italy) and iodopividone 0.5% (Betadine®, Meda Pharma S.p.A.; Milano, Italy), the ulcer healed. Six months after healing, a new wound arose on the scar (Figure 2). Several biopsy specimens were obtained from the margin of the ulcer and a diagnosis of BCC of the lower leg was established. The patient received a total excision of the lesion and the defect was covered with a split-thickness skin graft. Surgical excision of the remaining skin lesions, histologically identified as BCC, was then performed. The excision margins were free of tumour and the patient has been symptom-free ever since. Skin cancers are associated with significant morbidity, especially in patients with recurrent or multiple simultaneous tumours, burdened by years of surgeries and the resultant economic, social and emotional costs of treatment and possibly, disfigurement. The hope for such patients is to develop Figure 1 First observation: shallow ulcer on the lower third of the right leg.