Tiziano Pallara

Three cases of embolia cutis medicamentosa (Nicolau’s syndrome)

Embolia cutis medicamentosa, also known as Nicolau’s syndrome, is a rare complication due to i.m. injections. Its real incidence is actually underestimated. Many drugs have been associated with it, but at the time only a few studies showed a related pathogenetic mechanism. Symptoms consist of immediate local pain, edema and cutaneous, subcutaneous and even muscular necrosis occurring in the first 48 h. The type of treatment depends mostly on time of diagnosis. A medical resolution can be achieved through heparin and cortisone injections within the first 48 h. Surgical debridement has to be considered as the main treatment in case of late diagnosis. We present three cases of Nicolau’s syndrome presenting to us in a short period of time that we treated with surgical debridement.

Treatment of Early-Stage Pressure Ulcers by Using Autologous Adipose Tissue Grafts

Assessing pressure ulcers (PUs) in early stages allows patients to receive safer treatment. Up to now, in addition to clinical evaluation, ultrasonography seems to be the most suitable technique to achieve this goal. Several treatments are applied to prevent ulcer progression but none of them is totally effective. Furthermore, the in-depth knowledge of fat regenerative properties has led to a wide use of it. With this study the authors aim at introducing a new approach to cure and prevent the worsening of early-stage PUs by using fat grafts. The authors selected 42 patients who showed clinical and ultrasonographic evidence of early-stage PUs. Values of skin thickness, fascial integrity, and subcutaneous vascularity were recorded both on the PU area and the healthy trochanteric one, used as control region. Fat grafting was performed on all patients. At three months, abnormal ultrasonographic findings, such as reduction of cutaneous and subcutaneous thickness, discontinuous fascia, and decrease in subcutaneous vascularity, all were modified with respect to almost all the corresponding parameters of the control region. Results highlight that the use of fat grafts proved to be an effective treatment for early-stage PUs, especially in the care of neurological and chronic bedridden patients.

Versatility of Capsular Flaps in the Salvage of Exposed Breast Implants

Summary: Breast implant exposure due to poor tissue coverage or previous irradiation represents a surgical challenge both in the reconstructive and aesthetic plastic surgery practice. In case of implant extrusion or incipient exposure, the commonly suggested strategies, such as targeted antibiotic therapy, drainage and lavage of the cavity, fistulectomy, and primary closure, may be ineffective leading the surgeon to an unwanted implant removal or to adopt more invasive flap coverage procedures. Breast implant capsule, in its physiological clinical behavior, can be considered as a new reliable source of tissue, which can be used in a wide range of clinical situations. In our hands, capsular flaps proved to be a versatile solution not only to treat breast contour deformities or inframammary fold malpositions but also to salvage exposed breast implants. In this scenario, the use of more invasive surgical techniques can be avoided or simply saved and delayed for future recurrences.(Plast Reconstr Surg Glob Open 2015;3:e340; doi:10.1097/GOX.0000000000000307; Published online 30 March 2015.)

An electrical plasma dissection tool for surgical treatment of chronic ulcers: Results of a prospective randomised trial

Cutaneous ulceration is a difficult medical problem and a major source of morbidity for patients. In the surgical treatment of ulcers, debridement is the first step, and it can be carried out using several surgical tools. Recently, new surgical devices have emerged using plasma‐mediated electrical discharges with a lower peak temperature. A prospective single‐blind trial was conducted on chronic ulcers not responsive to common non‐surgical management. Patients were randomly separated into 2 groups: Group A received surgical debridement with conventional electrocautery, and Group B received surgical debridement using the plasma‐mediated device. Histological samples were collected intraoperatively to evaluate the thermal damage during the surgical procedure and 2 weeks after surgery to evaluate the inflammatory response and collagen deposition. The width of coagulation necrosis at the incision margins in Group B was significantly shorter compared with Group A (P = .001). The inflammatory cell infiltration showed a cellular distribution percentage that was quite equal between the 2 groups. The granulation tissue showed an abundant deposition of dense and mature collagen in Group B, compared with Group A, where the mature collagen appeared in small quantities (P < .001). Microbial culture showed a lower incidence of postoperative infections in Group B compared with the control group (P < .05). The study demonstrated, based on the results, that the new technology with the use of a lower temperature electrosurgical device represents an effective therapeutic weapon for the surgical treatment of skin ulcers, both vascular and extravascular types.

Outcomes of Traditional Cosmetic Abdominoplasty in a Community Setting

Because of the variability and variety of factors associated with abdominoplasty, surgeons must be well cognizant of potential complications and outcomes. The authors discussed patient preoperative assessment, restrictive and malabsorptive operations, and outcomes. Most important are the possible complications of the procedure and the effects on quality of life, self-esteem, and emotional stability.

Freestyle perforator flaps: an innovative approach to soft tissue reconstruction

Resurfacing of soft tissue defects consequent to skin cancer, melanoma, or sarcoma excision in different anatomical districts represents a difficult challenge for the plastic surgeon. Classic reconstructive procedures are frequently charged by unsatisfactory results. The introduction of perforator flaps in the clinical practice represented a revolution in the field of reconstructive plastic surgery. The technique further evolved with the introduction of the freestyle concept, allowing one to harvest a skin flap from any region of the body where an appropriate and detectable Doppler signal is present and to resurface soft tissue defects mobilizing the surrounding tissues, which present similar features compared with the recipient site in terms of color and texture, on a consistent vascular source and in a tension‐free manner. The authors present their personal approach to the reconstruction of soft tissue defects after excision for a basal cell carcinoma involving the medial tibial region.

Achieving an optimal cosmetic result with excision of lesions on the face.

To the Editor: W e read with great interest the article by Hudson showing how to achieve an optimal cosmetic result with the excision of lesions on the face. We agree with the author that several approaches may be used, depending on different situations. Defects caused by excision of malignant tumors of nasal alae and perinasal areas are conventionally repaired with locoregional pedicled flaps. However, second-intention healing may represent a valid option. Furthermore, referring to simple excision and healing by secondary intention option, we think that possible distortion of ala may be avoided by performing a ‘‘guided excision.’’ Here we present a case of a man who was referred to our outpatients’ clinic with an epithelioma on his left nasal fold. We planned tumor excision lines besides its clinical margins, considering the subunits’ limits. Therefore, incisions were performed parallel to the limits of nasal subunits. As shown in Figure 1A, the tumor was excised in an elliptical shape, avoiding the rounded perilesional loss. We thought that this approach splits vector lines and guides directional healing. At 4 weeks from surgery, in fact, the wound had completely healed and reepithelialized. Furthermore, final results after 12 months maintained the patient’s nasal contour, with no distortion of the alar rim (Fig. 1B). Small defects are usually repaired by direct closure when it is possible where larger defects require the use of flaps or grafts. In the nasal reconstruction, the most commonly used local flaps are either bilobed flap or advancement V-Y flaps (nasojugal island flaps). In the last decades, enthusiasm for reconstructive techniques has largely overshadowed ideas related to the efficacy and safety of spontaneous granulation. Furthermore, second-intention healing has important advantages: it obviates the need for hospitalization, it allows the observation of tumor recurrences that have a high risk to arise again, wound management is easier and rarely painful, and major complications (hematomas, seromas, flap necrosis, and graft loss) are avoided. Concerns related to secondary intention healing include unpredictability and suboptimal cosmetic and functional results associated with prolonged healing time as well as bleeding and infection. However, factors such as the anatomical location of the defect, skin color, wound size, and depth have been shown to be helpful for predicting results of secondary intention healing. Finally, we think that secondary intention healing is a safe and effective alternative to surgical reconstruction after a radical excision of malignant lesions of nasal alae and perinasal areas, if performed correctly. In the authors’ opinion, this approach within these particular subunits is not just a secondary option. It should be considered as a valid alternative instead.