Riccardo Gazzola

The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers.

Hyaluronidases, a family of enzymes that are able to degrade hyaluronic acid (HA), are employed in medicine to increase drug diffusion and reverse the effects of HA filler injections. Hyaluronidases are able to dissolve subcutaneous nodules or to correct excessive quantities of injected filler. Knowledge of the use, methods of application, and adverse effects of hyaluronidases is essential for the aesthetic practitioner. Therefore, we performed an extensive review of the available literature from 1928 to 2011 and compared the different enzymes available, recording each authors indications regarding usage and side effects.

Perineural fat grafting in the treatment of painful end-neuromas of the upper limb: a pilot study.

The purpose of this study was to evaluate the effectiveness and middle-term durability of the results achieved with perineural fat grafting of painful neuromas of the upper limb. We retrospectively analysed eight patients, affected by eight neuromas, treated by neuroma excision and fat grafting around the proximal nerve stump. Clinical parameters, the disabilities of the arm shoulder and hand score, and the visual analogue scale were recorded at 2, 6 and 12 months after surgery. A reduction of 23.2% was observed in the mean disabilities of the arm shoulder and hand scores at 12 months. The spontaneous baseline visual analogue scale score showed a mean improvement of 22% at 12 months, although not this was not statistically significant. Perineural fat grafting is a quick and useful procedure and could represent a useful primary operation in the treatment of pain syndromes of neuropatic origin.

Perineural fat grafting in the treatment of painful neuromas.

Treatment of painful neuromas of the upper limb has been largely debated. The current surgical treatments spare from simple neuroma excision to proximal nerve stump relocation (into muscles, veins, and bones). Perineural fat grafting consists of neuroma excision and the creation of an autologous adipose graft wrapped around the proximal nerve stump. This technique should be prescribed to those patients suffering from terminal neuromas or neuromas in which functional reconstruction is contraindicated. The effectiveness of this technique could be addressed both to the mechanical and biological properties of the fat graft. On one hand the graft creates a gliding layer and a protective barrier, thus allowing longitudinal excursion and protection against mechanical solicitations. On the other hand the autologous adipose tissue brings neoangiogenesis, modulates the inflammatory response, and avoids scar adherences. A retrospective analysis was performed on 7 neuromas in 7 patients, treated with perineural fat grafting from June 2009 to February 2010. Pain and limb functionality were measured, respectively, with a visual acuity scale and the “Disabilities of the Arm, Shoulder, and Hand score,” preoperatively and 1 year after surgery. A mean pain reduction of 23% was recorded, without relevant complications. Improvements in limb functionality were also observed through the measurement of the Disabilities of the Arm, Shoulder, and Hand score, which improved to 18%. We believe that this technique represents a valuable and versatile option in the treatment of painful neuromas of the upper limb that could be hereafter performed for pain syndromes of neuropatic origin.

Failure by congestion of pedicled and free flaps for reconstruction of lower limbs after trauma: the role of negative-pressure wound therapy

Lower limb reconstruction with pedicled or free flaps can be commonly compromised by venous insufficiency. This complication often leads to partial/complete flap necrosis and increases the risk of superinfection. Negative-pressure wound therapy (NPWT) is known to increase local blood flow, decrease edema, promote tissue granulation, and reduce the likelihood of soft tissue infection. This study aims to evaluate the effectiveness of NPWT in the treatment of congested pedicled and free flaps of the lower limb after reconstructions in lower limb traumas. A retrospective analysis was performed on four congested (pedicled and free) flaps on the lower limbs. NPWT was applied in all cases after partial flap debridement. NPWT was able to improve and resolve tissue edema and venous insufficiency, avoid further flap necrosis, and promote granulation. On NPWT removal, a split-thickness skin graft was applied on the wound, achieving complete and uneventful healing. NPWT is a useful instrument in managing flaps affected by venous insufficiency in lower limb reconstruction, although larger studies are necessary to better define the effectiveness and indications of NPWT in this setting.

Distally based sural fasciomusculocutaneous flap for treatment of wounds of the distal third of the leg and ankle with exposed internal hardware

Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.

First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

BackgroundFractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.Methods13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.ResultsWound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).ConclusionOur approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

Poly implant prothèse asymmetrical anatomical breast implants: a product recall study.

Background: In 2010 high rupture rates were unexpectedly found among prostheses produced by the French manufacturer Poly Implant Prothèse. Since then, several studies have been performed concerning the round implants, but there are still few data available on anatomical implants. Methods: From 2003 to 2006 Poly Implant Prothèse implants were employed at the authors’ institute for immediate or delayed reconstruction after mastectomy. All implants were anatomical and asymmetrical. In November of 2010, the authors began offering free consultation with a plastic surgeon and radiologist. Demographic data, type of reconstruction, implant lifespan, indications for implant removal, and rupture rate were recorded. Results: A total of 578 women underwent postmastectomy immediate or delayed reconstruction with 658 Poly Implant Prothèse implants from 2003 to 2006 at the authors’ institute. The authors explanted 409 of 443 prostheses, and 34 were explanted at other centers. Eighty-nine patients died and 120 are alive with the implants in place. The mean implant lifespan was 57.5 months, 76 ruptured implants were explanted (18.5 percent), and in 22 cases (5.4 percent), leakage of silicone gel was detected. Conclusions: Poly Implant Prothèse implant failure is to be ascribed to shell structure, although the primary safety issue concerned the gel (an industrial-grade and low-cohesive silicone). These issues produce the known rupture rates in the manufacturer’s round implants. The authors’ use of only anatomical and asymmetrical implants, with their more cohesive silicone gel and more rigid shell allowing a stable form and projection along with a natural feel and touch, probably reduces the rupture rate and silicone spread, although these events remain unacceptably high compared with similar products of other brands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Herpes virus outbreaks after dermal hyaluronic acid filler injections.

Herpes virus outbreak after dermal filler injection is a rare but troublesome complication, caused by virus reactivation. Herpes simplex virus 1 (HSV-1) is often involved (according to data released by the FDA, the incidence does not exceed 1.45% of cases), whereas herpes zoster (HSZ) onsets are more rare.1 Many adverse effects after facial filler injections have been widely described and discussed by several authors,2,3 but the literature is scant regarding HSV and HZV reactivations after hyaluronic acid filler injections. The family of herpesviridae includes HSV-1, herpes simplex virus 2 (HSV-2), herpes zoster virus, Epstein-Barr virus, cytomegalovirus, human herpes virus 6, human herpes virus 7, and human herpes virus 8. Clinical reactivations after dermal filler injections have been described for herpes simplex and herpes zoster viruses. These viral agents have in common the double-stranded linear DNA that replicates inside the nucleus and their capability for latent and persistent infection. Herpes simplex viruses are characterized by mucocutaneous infections, although systemic infections have been rarely described. HSV-1 is classically associated with labial infections and cranial localizations, whereas HSV-2 consists of the etiologic agent of herpes simplex genitalis. Recently, it has been shown that in some populations, HSV-1 is the most frequent cause of herpes genitalis.4 The varicella zoster virus occurs both in children (primary infection, chicken pox) and adults (secondary infection, herpes zoster). The virus penetrates through the respiratory …

Chronic Ulcer by Cutaneous GvHD After Bone Marrow Transplantation Treated With Skin Allograft From HLA-Identical Donor Case Report and Literature Review

We present a successful split-thickness skin allograft for a chronic cutaneous graft-versus-host disease of the thigh in an immunosuppressed patient, treated for acute myeloid leukemia with allogenic bone marrow stem cells transplant.

Surgical excision of Infantile Haemangiomas: a technical refinement to prevent bleeding complications

PURPOSE The aim of the study is to improve operative speed and precision of haemangiomas excision. METHODS CASE-REPORT haemangioma is a common affection of the 8% of the population during the neonatal period. In complicated cases and involution sequelae surgical treatment is the first choice. The Authors propose a surgical refinement to prevent intraoperative bleeding. METHODS several suture stitches were placed around the hemangioma. The edges of the lesion became more defined, thus allowing accurate excision. RESULTS AND CONCLUSIONS Haemangiomas are characterized by rich blood supply. Surgery is often hindered by massive bleeding and Temporary placement of full-thickness sutures, surrounding the hemangioma, allowed a noticeable improvement in hemostasis precision and greater definition of the margins of the hemangioma.