Coagulation Disorders And Mortality In Burn Injury: A Systematic Review

Even though coagulopathy is a familiar entity in trauma, its relationship to burn injury remains unclear. Literature appears inconsistent as to the conclusions of the use of coagulation assays, either routine methods or newer viscoelastic coagulation assays (VCAs), thromboelastography (TEG) and rotational thromboelastometry (ROTEM), for prediction of patients' coagulation status and mortality. The use of diagnostic assays as mortality markers will be of great importance, since they would recognize at early stages patients with great medical demands and objectify burn injury severity. The aim of this study was to review the literature and evaluate burn patients' characteristics and coagulation markers in the early post burn period. The secondary outcome was to investigate the role of different coagulation assays in mortality prognosis. Literature search was performed using PubMed, ScienceDirect, Wiley Online Library, Google Scholar, Proquest Dissertation and Theses Global, Scopus and Cochrane Library databases. All types of articles referring to adults with any type of burn injury admitted in the first 24h assessing coagulation and mortality were included. PRISMA guidelines ensured the evidence-based process. Eleven studies met the eligibility criteria. This review demonstrated the indubitable relationship of coagulopathy with burn injury and its significant impact on mortality. The rapid and dynamic process of coagulation makes standard coagulation assays unable to detect short-lived haemostatic changes. More susceptible markers such as VCAs need to be applied to the routine assessment of burn patients in order to obtain an overview on coagulopathy and standardize the gained knowledge.

Tracking the risk factors associated with high-risk cSCC: A 10-year, Two-Institution, Greek study

PURPOSE

We sought to identify independent risk factors for positive sentinel lymph node biopsy (SLNB), local recurrence (LR), metastasis (M) and death caused by cutaneous squamous cell carcinoma (cSCC) (DCS) in high-risk cSCC patients. Moreover, we compared the Brigham and Women's Hospital (BWH) system with the previous used in Greece (based on tumor size) and proposed a new classification system.

METHODS

1,524 cSCC patients were enrolled between January 2004 and December 2014, from two medical institutions. Potential risk factors for SLNB (local recurrence/LR, metastasis/M, death caused by SCC/DCS) were analyzed by univariate and multivariate Cox logistic regression models.

RESULTS

Of the included patients with a median follow-up of 60 months 107 developed local recurrence (7%) while 84 developed metastases (5.5%). Among 36 patients undergoing sentinel lymph node biopsy (SLNB), 25% showed a positive SLNB with a false-negative result (11%). On multivariate analysis, key prognostic factors for LR were tumor diameter ≥2 cm, poor differentiation, incomplete excision and perineural invasion and for M were high-risk tumor site, tumor diameter ≥2 cm, poor differentiation, invasion beyond subcutaneous tissue, incomplete excision, perineural invasion and recurrence. DCS seems to be affected by tumor diameter ≥ 2 cm, poor differentiation, invasion beyond subcutaneous tissue, incomplete excision, perineural invasion and recurrence independently.

CONCLUSIONS

These suggest the determined role of tumor diameter of cSCCs. Harnessing knowledge and collecting the up-to-date data along the clinical journey of high-risk cSCC, the future looks bright (development of new clinical trials, adjuvant therapies and tumor staging with SLNB).

Advances in Dermoepidermal Skin Substitutes for Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalisation and non-traumatic lower limb amputations. Multidisciplinary management, patient education, glucose control, debridement, off-loading, infection control, and adequate perfusion are the mainstays of standard care. Despite all these, at least 30% of DFUs fail to heal within 20 weeks. Therefore, dermoepidermal skin substitutes (DSS) have been used as a new therapeutic adjunct for DFUs. This brief review outlines the recent advances in DSS for the treatment of DFUs. PubMed and Cochrane databases were systematically searched in May to July 2018 for systematic reviews published after 2013 and for randomised controlled trials (RCTs). A retrospective evaluation of 28 RCTs was performed. Rates of complete wound closure and time to healing were examined for 17 commonly available DSS. Healing rates after 12 weeks and time to complete closure in DFUs are heterogeneous among the 28 RCT. The best healing rates at 12 weeks were accomplished with dermal cellular substitutes (Epifix®, 100% and Amnioband®, 85%) and with dermal acellular substitutes (Allopatch®, 80% and Hyalograft®, 78.8%). Based on these studies, DSS used in conjunction with standard care appear to improve the healing rates of DFUs, as compared with standard care alone. Nonetheless, new studies with more homogeneous samples are needed to ascertain the role of ulcer size, duration, depth and/or type in the efficacy of DSS. Moreover, future RCTs should include patients with severe comorbidities, in order to be more representative of clinical reality.

Adipose-Derived Mesenchymal Stem Cells in the Treatment of Diabetic Foot Ulcers: A Review of Preclinical and Clinical Studies

This review provides an outline of the use of adipose-derived mesenchymal stem cells (AMSCs) in the treatment of diabetic foot ulcers (DFUs). A systematic search of PubMed and the Cochrane database was performed on October 2, 2019. Eighteen studies were identified (14 preclinical and 4 clinical). Studies in animal models have demonstrated that AMSCs enhance diabetic wound healing, accelerate granulation tissue formation, and increase reepithelialization and neovascularization. Only 1 randomized control trial has been published so far. Patients (n = 25) with DFUs were treated using an allogeneic AMSC directly on the wound bed as a primary dressing, and improvements were found in complete wound closure in the treatment group (n = 16). Three clinical studies showed that autologous AMSC might be a safe alternative to achieve therapeutic angiogenesis in patients with diabetes and peripheral arterial disease. Based on the available evidence, AMSCs hold promise in the treatment of DFUs. However, this evidence requires confirmation by well-designed trials. Additional studies are also required to understand some issues regarding this treatment for DFUs. For example, the potential application of autologous or allogeneic AMSCs in different types of DFUs, optimal dose/infusion schedules, safety evaluations, and cost-effectiveness.

The Greek Surgeon-Gynecologist Savvas Georgiadis (1857-1942) and the First Vaginal Reconstruction in Smyrna

The Greek surgeon-gynecologist Savvas Georgiadis from Phocaea in Asia Minor had performed in 1897 an innovative surgical operation in a young female patient, reconstructing her vagina. Having been educated both in Greece and France, specialized in gynecology, he became a famous surgeon in the Hellenic Hospital of Smyrna "Agios Charalampos," where the operation was masterfully executed. Although among the pioneers in neovagina techniques, Georgiadis still is searching his place among the important figures in the history of plastic surgery.

Tips and Outcomes of a New DIEP Flap Inset in Delayed Breast Reconstruction: The Dual-Plane Technique

Purpose The dual-plane deep inferior epigastric perforator (DIEP) flap inset technique is herein presented with tips for optimizing the aesthetic outcome in delayed autologous breast reconstruction after radiation therapy. Patients and Methods A total of 42 women who underwent microsurgical reconstruction with a free DIEP flap participated in this prospective study. The flap was inset in a dual plane lying behind the pectoralis major at the upper pole and in front of the muscle at the lower pole of the reconstructed breast. Results The dual-plane flap inset resulted in natural transition from native and reconstructed tissues, excellent scar quality, optimal outline of the breast, and overall breast appearance. Moreover, dual-plane reconstruction was associated with constantly high patient satisfaction without wearing brassiere due to fullness of the upper pole and minimal ptosis with time. Conclusion The dual-plane DIEP flap inset results in optimal scar quality, breast shape, and fullness of the upper pole, resulting in high patient satisfaction.

Histological Comparison of the Human Trunk Skin Creases: The Role of the Elastic Fiber Component

OBJECTIVE

Skin creases are features of major anatomical, morphological, surgical, and functional interest. This study focuses on the histological comparison of creases of the trunk and participation of the elastic fibers in their formation. The histological structure is a key consideration for the reconstructive planning of the relevant area and its knowledge may contribute in such direction.

METHODS

Fresh cadaver specimens were collected from the inframammary (n = 15), infragluteal (n = 16), and inguinal creases (n = 14), the anterior axillary fold (n = 14), and the surrounding skin (n = 10). Specimens were fixed in 10% buffered formaldehyde. Collagen and muscle fibers were stained by Masson Trichrome and Van Gieson stains, reticular and collagen type III fibers by Reticulin stain, and elastic fibers by Verhoef and Orcein stains.

RESULTS

Skin creases of the trunk present well-defined dense bundles of collagen fibers, creating a beehive pattern with broad attachment to the dermis and denser in deeper sites related to the fascia of the underlying muscle. The elastic fibers participate in the collagen pattern and radiate in a parallel pattern in the reticular dermis and in a perpendicular fashion in the papillary dermis. The skin surrounding the creases lacks such organization.

CONCLUSIONS

Creases of the trunk are formed by well-organized collagen bundles in a beehive pattern, attached to the dermis and related to the underlying muscle fascia. The elastic fibers participate in this structure and radiate in a parallel fashion in the reticular dermis and perpendicularly in the papillary dermis.

How to Close a Limb Fasciotomy Wound

Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. A thorough search of medical databases PubMed/MEDLINE, ScienceDirect, SCOPUS, EMBASE, and Google Scholar was conducted for articles published between 1976 and 2013 using the search terms “limb fasciotomy wound closure,” “open wound management,” “skin stretching,” and “fasciotomy complications.” A total of 49 articles on technique descriptions, case reports of 2 or more patients, and of complications and comparative studies regarding limb fasciotomy wound closure were included. Details of the duration of treatment, advantages and disadvantages, direct cost, and complications were data extracted for each technique from the 49 studies included in this overview. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time and is also crucial for optimization of functional and aesthetic outcomes.

Autologous fat grafting: in search of the optimal technique

OBJECTIVE

Recent advances in adipose cellular biology have repopularized autologous fat grafting as a method widely used in both reconstructive and aesthetic surgery. This review aims to summarize our current knowledge on autologous fat grafting emphasizing harvesting techniques and processing methods as well as current trends and approaches.

METHODS

A thorough search of earlier and recent literature until October 2013 was conducted using the terms autologous fat grafting, autologous fat transfer, lipoaspirate, lipoinjection, fat harvest, and lipotransfer in PubMed and ClinicalTrials.gov databases, and relevant English- and German-language articles were included.

RESULTS

Findings were categorized in a step-by-step approach of the fat grafting procedure into indications, selection of donor site, techniques for harvesting, processing, and reimplantation of autologous fat.

CONCLUSIONS

Further in-depth knowledge will provide definite answers on fat graft survival; demonstrate safe methods to increase cell viability, grafting outcome predictability; and reliability; enhance safety; and strengthen the scientific and clinical establishment of this increasingly promising method.

Patient-related delay in presentation for cutaneous squamous cell carcinoma. A cross-sectional clinical study

BACKGROUND

Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC.

PATIENTS AND METHODS

A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed.

RESULTS

Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation.

CONCLUSION

Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC.

Current achievements with topical negative pressure to improve wound healing in dehiscent ischemic stumps of diabetic patients: a case series

Negative pressure wound therapy has been increasingly used either as a primary or as an adjunctive therapeutic measure to treat a variety of recalcitrant wounds during the past years. It is thought to act by creating a local environment that promotes cell proliferation, angiogenesis, and granulation tissue formation, leading to accelerated wound healing to the point of spontaneous closure or reducing the wound size to facilitate significantly further surgical reconstruction. This case series presents our preliminary experience with the use of a Topical Negative Pressure system in the treatment of challenging ischemic wounds of diabetic patients. It aims to underscore its beneficial effects and explore its potential role in the management of ischemic amputated stumps to avoid ipsilateral re-amputation at a higher level.

Calcium sulfate cement in contained traumatic metaphyseal bone defects

The aim of this study was to evaluate prospective patients with periarticular fractures where a meta physeal bone defect was grafted with high compressive calcium sulfate cement. The calcium sulfate cement MIIG X3, (Wright Medical Technology, Inc, Arlington, TN) was used in 45 patients with periarticular fractures--distal radial, tibial plateau, humeral head, and calcaneal fractures--to fill the metaphyseal defect. All fractures were treated either with open or closed reduction, fracture fixation, and the cement was applied openly or closed. Radiographs were evaluated for fracture reduction, joint line gap, and step, as well as for rate of graft replacement by bone. All fractures united without an additional procedure. There were no wound infections or other complications attributed to the graft. At three-month follow-up, a complete graft replacement by bone was observed in all fractures. Joint line step was not developed in any patient, but a joint line gap of 3 mm was observed postoperatively in one patient with a tibial plateau fracture. Loss of reduction occurred in one patient with an extra-articular distal radial fracture treated with closed reduction and k-wire fixation. Cement that escaped into the joint or the surrounding soft tissues was not visible at the six-week follow-up. In conclusion, the results of this study confirm the safety and the efficacy of this cement when it is used as graft with the appropriate fixation method in traumatic metaphyseal bone defects.

Local infiltrative anesthetic effect of tramadol compared to lidocaine for excision of cutaneous lesions: pilot randomized, double-blind clinical study

BACKGROUND

In this double-blind, randomized study, the efficacy of tramadol, an atypical opioid, was tested versus lidocaine in excision of cutaneous lesions of the face.

METHODS

Eighty-eight patients were randomly assigned to receive either 2 mg/kg tramadol 2% plus adrenaline 1:200,000 (group T, n  =  46) or 3 mg/kg lidocaine 2% plus adrenaline 1:200,000 (group L, n  =  42) for excision of cutaneous lesions. Pain at the injection site, 2 and 20 minutes postinjection and 3, 6, and 12 hours postoperatively, was monitored on a 0 to 10 numerical rating scale (NRS). Irritation at the injection point and the duration of postoperative analgesia were also recorded.

RESULTS

There were no significant differences in demographic data, topography, size of the lesions removed, and operative time between the two groups. A tendency toward lower injection NRS pain scores was observed in group L compared to group T (p  =  .064). No statistically significant differences between the two groups were found at 2 and 20 minutes postinjection (p  =  .741 and p  =  .142, respectively); however, pain scores were significantly higher in group L at 3, 6, and 12 hours postoperatively (all p < .001). Erythema at the injection site was observed in nine group T and two group L patients (p  =  .076). No postoperative analgesics were required in the tramadol group of patients, whereas acetaminophen with or without codeine was administered in all but five lidocaine group patients during the first 12 hours.

CONCLUSION

Tramadol may be used as a reliable local anesthetic agent, providing longer postoperative analgesia compared to lidocaine; however, it bears a higher incidence of irritation at the injection site.

Is expansion of artificial dermis a reliable reconstructive option?

Reconstruction of full-thickness defects with the use of artificial dermis has been well established in the recent literature. The capacity of artificial dermis to expand over a period of years, months, or even days is described. Three such cases are reported. Two female patients, aged 21 and 30 years, with post-burn contractures of the chest with right breast hypoplasia and abdominal wall post-burn contractures respectively, and a 14-year-old male with a giant congenital naevus on the forearm, are presented. After excision of the contractures and the congenital naevus, the patients underwent staged reconstruction with the use of artificial dermal template and split-thickness skin autografts at monthly intervals. The 21-yr-old female also had a tissue expander placed submuscularly which six months later was replaced by a permanent silicone implant. Gradual expansion of artificial dermis within three weeks resulted in reconstruction of a breast of natural shape, size, and volume. In the second patient the artificial dermis was expanded over a period of months, until full-term pregnancy, while the third patient took years to achieve expansion naturally as he grew up. In conclusion, artificial dermis can be expanded over various periods of time (days to years), providing a reliable and safe alternative reconstructive method, particularly in areas where expansion is an absolute necessity for a good functional and aesthetic result.

Stem cell therapy for idiopathic pulmonary fibrosis: a protocol proposal

Background

Idiopathic pulmonary fibrosis represents a lethal form of progressive fibrotic lung disorder with gradually increasing incidence worldwide. Despite intense research efforts its pathogenesis is still elusive and controversial reflecting in the current disappointing status regarding its treatment. Patients and Methods: We report the first protocol proposal of a prospective, unicentric, non-randomized, phase Ib clinical trial to study the safety and tolerability of the adipose-derived stem cells (ADSCs) stromal vascular fraction (SVF) as a therapeutic agent in IPF. After careful patient selection based on functional criteria (forced vital capacity-FVC > 50%, diffuse lung capacity for carbon monoxide-DL_CO > 35% of the predicted values) all eligible subjects will be subjected to lipoaspiration resulting in the isolation of approximately 100- 500 gr of adipose tissue. After preparation, isolation and labelling ADSCs-SVF will be endobronchially infused to both lower lobes of the fibrotic lungs. Procedure will be repeated thrice at monthly intervals. Primary end-point represent safety and tolerability data, while exploratory secondary end-points include assessment of clinical functional and radiological status. Results: Preliminary results recently presented in the form of an abstract seem promising and tantalizing since there were no cases of clinically significant allergic reactions, infections, disease acute exacerbations or ectopic tissue formation. In addition 6 months follow-up data revealed a marginal improvement at 6-minute walking distance and forced vital capacity.

Conclusions

Adipose tissue represents an abundant, safe, ethically uncontested and potentially beneficial source of stem cells for patients with IPF. Larger multicenter phase II and III placebo-controlled clinical trials are sorely needed in order to prove efficacy. However, pilot safety studies are of major importance and represent the first hamper that should be overcome to establish a rigid basis for larger clinical trials.

Calcific uremic arteriolopathy treated with cinacalcet, paricalcitol, and autologous growth factors

BACKGROUND

Calcific uremic arteriolopathy is an uncommon cutaneous ischemic necrotizing disease, most commonly associated with renal disease and hyperparathyroidism, bearing a high mortality rate.

OBJECTIVE AND METHOD

A case of a 57-year-old female renal patient with hyperparathyroidism who was successfully treated with combined paricalcitol and cinacalcet systemically, while autologous growth factors were locally applied, is herein presented.

RESULT AND CONCLUSION

The combination of cinacalcet and paricalcitol is a reliable alternative to parathyroidectomy in patients with calcific uremic arteriolopathy and hyperparathyroidism. Meticulous débridement of necrotic tissues is essential and application of autologous growth factors promotes healing.

Giant dermoid cyst of the lower limb: presentation of a rare case

BACKGROUND

Dermoid cysts are unusual neoplasms that often present in childhood and are usually located in the head and neck region.

OBJECTIVE AND METHOD

We describe a rare case of a giant dermoid cyst of congenital inclusion type located at the lower extremity of a young male. Preoperative imaging studies were performed for evaluation of the mass.

RESULT

The cyst was surgically removed, and histopathologic examination confirmed the diagnosis.

CONCLUSION

Dermoid cysts rarely appear in the lower extremity and must be included in the differential diagnosis of cystic lesions of the lower limb.

Lanarkshire Oximetry Index as a Diagnostic Tool for Peripheral Arterial Disease in Type 2 Diabetes: A Pilot Study

We evaluated the Lanarkshire Oximetry Index (LOI) for the diagnosis of peripheral arterial disease (PAD) in type 2 diabetic patients, using the Ankle-Brachial Index (ABI) as gold standard. We included 161 patients (71 men, mean age 63.1 ± 9.8 years). Peripheral arterial disease was defined as ABI < 0.9. Two cut-off values of LOI (<0.9 and <0.8) were assessed for the diagnosis of PAD. Sensitivity and specificity for PAD were 93.3% and 89.1%, respectively, using a LOI cut-off value of 0.9, while they were 40% and 99.3%, respectively, using a LOI cut-off value of 0.8. Agreement between LOI and ABI was moderate (P < .001). There was a significant positive correlation between ABI and LOI (r = .377, P < .001). Lanarkshire Oximetry Index is a potentially useful alternative diagnostic test for PAD in type 2 diabetes. A cut-off value of 0.9 has high sensitivity and modest specificity. Agreement between LOI and ABI is moderate.

The efficacy of Helix aspersa Müller extract in the healing of partial thickness burns: a novel treatment for open burn management protocols

Snail extracts have been increasingly used in numerous dermatologic conditions and recent literature attributes healing, soothing and anti-aging properties to them. This study evaluates the efficacy of Helix aspersa extract in an open wound management protocol for deep partial thickness (PT) facial burns and compares it to moist exposure burn ointment(MEBO). A total of 27 adult patients with deep partial thickness facial burns (group A) were treated by application of a snail extract cream twice daily for a maximum period of 14 days or until full epithelialization. Times until debridement and epithelialization of the burn surface were compared with those of 16 patients (group B, control) treated by MEBO. Pain scores were recorded using a visual analogue scale (VAS) on the fourth post-burn day before and 30 min after application. Mean times for eschar detachment were 9 +/- 2 days (group A) and 11 +/- 2 days (group B) (p = 0.003) and for burn surface epithelialization were 11 +/- 2 days and 15 +/- 3 days respectively (p < 0.001). VAS pain scores after application in group A were significantly lower compared to group B (p < 0.001). Helix aspersa extract is a natural, safe and effective alternative treatment in open wound management of partial thickness burns in adults.

Rigorous Vibrio vulnificus soft tissue infection of the lower leg in a renal transplant patient managed by vacuum therapy and autologous growth factors

BACKGROUND

Vibrio vulnificus is a gram-negative marine bacterium that grows well in coastal waters. It is an opportunistic pathogen that can cause serious life-threatening infections in patients with certain health conditions. Vibrio-induced wound infections in immunosuppressed patients are difficult to treat because the healing process may be significantly delayed. Reconstructive surgery may not be successful in early treatment as skin grafts are likely to fail, and there may be increased morbidity of donor sites of grafts or flaps.

OBJECTIVE

Herein a case of septicemia and wound necrosis owing to V. vulnificus wound infection in a renal transplant patient is reported.

METHOD

To conservatively yet adequately débride the wound bed, stimulate angiogenesis, and accelerate granulation, vacuum-assisted closure was employed. Granulation was further enhanced by autologous platelet concentrate spray, which has also been reported to increase the epithelialization rate.

RESULT

Complete epithelialization of the wound was achieved 4 weeks after completion of treatment.

CONCLUSION

Noninvasive advanced modalities may be employed to successfully treat infectious soft tissue deficits in immunocompromised patients.

Dermal skin template for the management of multiple cutaneous leiomyomas

BACKGROUND

Multiple leiomyomas are rare benign tumors of the skin, originating from the arrector pili muscle, and usually appear as painful nodules. Several pharmacologic agents have been used with some success to reduce pain and discomfort since surgery may be an impractical approach owing to the extent of the disease.

OBJECTIVE

This article reports on a patient with multiple cutaneous leiomyomas of the upper limb who was managed by a method not previously reported for leiomyomas.

METHOD

The management involved total surgical resection of the defect and immediate reconstruction with the Integra artificial dermal template (Integra LifeSciences Corp., Plainsboro, NJ).

RESULTS

With this treatment, the patient was totally relieved from the pain, and optimal functional and esthetic results were achieved.

CONCLUSION

Complete surgical resection of multiple cutaneous leiomyomas prevented the disease's recurrence. The immediate reconstruction of the resultant full-thickness defect with artificial dermis ensured uneventful wound healing, resulting in optimal functional and esthetic outcome and total relief from leiomyoma-associated discomfort.

Preservation of venous outflow improves transverse rectus abdominis musculocutaneous flap survival following vascular delay

BACKGROUND

The rat abdominal island model has proved to be a reliable and reproducible model for the study of surgical delay procedures. It has been customary to simultaneously divide both the artery and the accompanying vein to obtain maximum survival of the rat TRAM flap undergoing delay procedure. This study evaluates the effect of selective arterial interruption compared to standard vascular delay on flap survival in the rat TRAM flap model.

METHODS

Thirty-six Wistar rats were randomly assigned to three groups (n=12), depending on the vascular ligation selected for the initial experimental delay stage. In group A (control group) no vessels were ligated. In group B the right deep inferior epigastric vessels were preserved and the right superior and left inferior and superior deep vessels were ligated. In group C the right inferior epigastric vessels and the left inferior epigastric vein were preserved while superior epigastric vessels and the left inferior epigastric artery were ligated. For the second stage one week later, TRAM flaps were elevated based on the right deep inferior epigastric vessels, re-inset in their original position and digitally photographed. Skin island viability was determined 96 hours later using digital photography and image-analysis software SigmaScan (SPSS, Inc., Chicago, IL).

RESULTS

The percentage of flap survival in control group A was 50+/-6%, in group B 60+/-4% and in group C 85+/-4%. The occlusion of the three vascular pairs in group B improved the survival percentage in comparison to the control group A, but this did not achieve statistical significance. In contrast, the percentage of flap survival in control group C was statistically significant compared to groups A and B (p<0.05, ANOVA). Zone IV exhibited no necrosis in any group C animals.

CONCLUSIONS

This indicates that delay with preservation of the venous outflow of zone IV results in increased blood supply.

Vacuum-assisted closure downgrades reconstructive demands in high-risk patients with severe lower extremity injuries

BACKGROUND

Primary soft tissue reconstruction in complex leg injuries is mandatory in order to protect exposed tissues; however, it may be precluded by the patient's clinical status or by local wound conditions. This retrospective study aims to evaluate the use of negative pressure as an adjunct to delayed soft tissue reconstruction in patients with complex lower limb trauma.

MATERIAL AND METHODS

Forty-two patients with 49 complex lower limb injuries were treated with Vacuum assisted closure (VAC) 48 hours after bone fixation, vascular repair and surgical debridement. Wound swab cultures were obtained before and after every VAC application. Duration of therapy, wound flora, final reconstructive technique required, outcome and follow-up period were retrieved from medical records.

RESULTS

Twenty-four male and eighteen female patients were recruited, with a mean age of 47 years. All were treated with VAC therapy for 15-42 days. Reconstruction was delayed due to the patients' critical condition, advanced age, medical co-morbidities, heavily exuding wounds and questionable viability of soft tissues. Patients were followed up for 90-895 days. Two wounds healed spontaneously, 6 were managed with delayed direct suture, 31 with split thickness skin grafts and 9 required local cutaneous, fasciocutaneous or muscular flaps. One patient died due to fat embolism. Wound bacterial flora progressively decreased in all but one patient. Scar formation was aesthetically acceptable by the patients while function depended on the initial injury.

CONCLUSIONS

Negative pressure is a safe and effective adjunct to delayed soft tissue reconstruction in high-risk patients with severe lower extremity injuries, minimizing reconstructive requirements and therefore postoperative morbidity.

Burned Breast Reconstruction by Expanded Artificial Dermal Substitute

Full-thickness anterior chest wall burns result in contractures that may restrict the development of breast in young female patients. The management of postburn contractured anterior chest wall scars and unilateral breast hypoplasia with the expansion of bilayered artificial skin is herein presented for the first time in literature to the best of our knowledge. A 21-year-old female with chest wall contractures after thermal injury she had suffered at the age of 27 months was managed in three stages. The first stage included release and excision of contractures and scars, submuscular insertion of anatomical tissue expander, and coverage of the anterior chest wall with Integra artificial skin (Skin, Johnson & Johnson Medical, Division of Ethicon, Inc., Sommerville, NJ). One month later, the outer silicone layer of Integra was substituted by a split-thickness skin autograft and the expander was partly inflated with saline. During the third stage and after overexpansion of the expander had been completed, the expander was removed and a permanent silicone implant was subsequently inserted. No immediate or late complications were observed. At 17 months, the breast contour remains stable, no recontracture has occurred, and the patient evaluates the result as very satisfactory. Expansion of artificial skin Integra appears to be a reliable and safe alternative for reconstruction of the burned breast, lacking the morbidity associated with deep donor sites of full-thickness skin autografts or flaps.

Intraoperative cytological evaluation of Marjolin ulcers

BACKGROUND

Marjolin ulcers are malignant neoplasia developing in chronic open wounds and pathological scars. A definitive diagnosis is made by histological examination of permanent sections. Frozen section biopsy has been widely used for intraoperative diagnosis and evaluation of surgical excision safety margins. This preliminary study aims to discuss the reliability of a simpler and faster method -- intraoperative cytology -- in the diagnosis of Marjolin ulcers.

PATIENTS AND METHODS

Touch or scrape smears of 76 Marjolin ulcers from 22 patients were assessed, and features were compared to the histological appearance of permanent sections.

RESULTS

Cytology revealed squamous cell carcinoma (SCC) in 45 ulcers from 11 patients. Histology confirmed SCC in 48 ulcers from 12 patients. No false-positive and one false-negative results were found. Cytology was found to have a 98.7% accuracy, 98% sensitivity and 100% specificity in the intraoperative diagnosis of Marjolin ulcers.

CONCLUSIONS

Cytology is a fast and reliable alternative in the intraoperative diagnosis of Marjolin ulcers.

Breastfeeding After Reduction Mammaplasty

Breastfeeding following reduction mammaplasty by using 3 different techniques is evaluated in this retrospective study. A questionnaire was sent to 178 patients who had undergone the operation at childbearing age and provided data on quality and duration of preoperative and postoperative breastfeeding, as well as reasons for not attempting or failing. Demographic data and operative details were obtained from patients' records. One hundred six of the patients who replied to the questionnaire and had given birth after reduction mammaplasty were included in this study. Breastfeeding was considered successful if it was performed for at least 3 weeks without supplementation. For women who attempted to breastfeed postoperatively, successful rates were 71% for superior pedicle mammaplasty, 77% for the inferior pedicle technique, and 63% following horizontal bipedicled reduction mammaplasty. However, 22% of women had not made any attempt to breastfeed at all after breast reduction. The postoperative ability to breastfeed was not found to relate to the amount of resected breast tissue or the time elapsing between operation and delivery. It is concluded that after breast reduction with pedicled transposition of the nipple-areola complex and preservation of adequate subareolar breast tissue, the ability to breastfeed highly depends on encouragement and support offered to women rather than the choice of the operative technique.

Levobupivacaine Versus Ropivacaine Infiltration Analgesia for Mastopexy

A prospective double-blind study was conducted to compare the analgesic properties of levobupivacaine and ropivacaine in a bilaterally symmetrical mastopexy model. Both of these 2 long-acting local anesthetic amides are associated with lower cardiac and central nervous system toxicity than racemic bupivacaine, a widely used agent for long-lasting perioperative analgesia in esthetic procedures. In this study, each of the 18 patients undergoing bilateral mastopexy under conscious sedation received preoperative infiltration with levobupivacaine in 1 breast and equal volume of ropivacaine in the other. Patients were requested to assess their pain separately in each side every 2 hours and for 12 hours postoperatively on a visual analog scale. Overall analgesia achieved up to 12 hours postoperatively was found to be statistically different between the 2 local anesthetic factors in favor of levobupivacaine. At 2 hours postoperatively, no difference was found between the 2 local anesthetic agents in terms of analgesic efficacy (P = 0.298). However, postoperative pain scores recorded after infiltration with levobupivacaine were significantly lower than pain scores for the ropivacaine-infiltrated sides (P<0.001) at all other timeframes. Both anesthetics provided satisfactory analgesia for at least 10 hours, but constantly low pain scores were recorded for levobupivacaine for 10 hours postoperatively, whereas for ropivacaine only for 6 hours. At 12 hours, 66% of patients needed oral analgesia for pain in the ropivacaine-infiltrated breast. It is concluded that levobupivacaine is more effective for local infiltrative analgesia in mastopexy than ropivacaine, providing longer-lasting postoperative analgesia.

Comparative efficacy of ropivacaine and bupivacaine infiltrative analgesia in otoplasty

A prospective double-blind study was conducted to compare the anesthetic efficacy of ropivacaine and bupivacaine in a bilaterally symmetrical otoplasty model. Because ropivacaine has a significantly lower toxic potential than bupivacaine, it may be established as the anesthetic agent of choice for low-dose infiltration anesthesia in routine aesthetic facial operations. Each of the 24 adult patients undergoing bilateral otoplasty received infiltration with ropivacaine in 1 auricle and an equal volume of bupivacaine in the other. Patients were requested to assess their pain separately in each side at the times of infiltration, during cartilage scoring, and 2, 6, and 10 hours postoperatively on a visual analog scale. Intraoperative success rates were similar, and overall analgesia achieved at 2 hours, 6 hours, and 10 hours postoperatively was not found to be statistically different between ropivacaine and bupivacaine. The authors conclude that ropivacaine can be used as an effective alternative to bupivacaine in otoplasty.

ALK-Positive Neutrophil-Rich Variant of Anaplastic Large Cell Lymphoma Diagnosed after Head Trauma

BACKGROUND

Anaplastic lymphoma kinase (ALK) expression has not been described in neutrophil-rich anaplastic large cell lymphoma (NR-ALCL).

CASE REPORT

A 12-year old female with a 4-weeks history of a non-resolving bump over the forehead resulting from injury, was diagnosed of stage IE cutaneous T-cell lymphoma, and radiation was employed. Shortly after completion of therapy, there was progress of the disease on the soft tissue of the right hand, and bone marrow involvement was also found. A fine-needle aspiration of the hand mass was performed, and a diagnosis of CD30+/ALK+ NR-ALCL, was rendered.

METHODS

We studied the morphological characteristics of CD30+/ALK+ NR-ALCL using histological methods. A panel of antibodies were used to establish diagnosis and subtyping. In addition EBV status and molecular cytogenetics were determined.

CONCLUSIONS

ALK-ALCL arising in the skin represents a single disease with a broad spectrum of morphology; clinicians and pathologists should be aware of this neutrophil-rich (NR) variant with aggressive clinical presentation.

Reduction mammaplasty specimens and occult breast carcinomas

AIM

The aim of this study was to report the incidence of occult cancer in reduction mammaplasty (RM) specimens.

METHODS

A retrospective study of 314 women who underwent RM from February 1996 to August 2001.

RESULTS

Occult carcinomas were detected in three patients, in two of which the lesions were invasive. Atypical ductal or lobular hyperplasia was found in five cases and other carcinoma risk lesions in four patients. Other benign changes were identified in totally 133 patients.

CONCLUSION

Incidental carcinomas will occasionally be found in RM procedures.

Systemic B-cell chronic lymphocytic leukemia first presenting as a cutaneous infiltrate arising at the site of a herpes simplex scar

Cutaneous infection by Herpes virus (simplex or zoster) is a common non-specific skin manifestation in patients affected by B-cell chronic lymphocytic leukemia (B-CLL) or other malignant lymphomas and is attributed to the patients' immunodeficiency. Persistent or shortly recurrent lesions, however, may represent specific cutaneous infiltrates of systemic B-CLL of several months' duration. The occurrence of these lesions as first manifestation of B-CLL is rare and previously reported only on herpes zoster scars. A case of a 63-year-old male patient with cutaneous B-CLL infiltrate of the right oral commissure at the site of herpes simplex scar as first sign of the disease is herein reported.

Brooke-Spiegler syndrome with parotid gland involvement

Salivary gland involvement in Brooke-Spiegler syndrome (BSS), an autosomal dominantly inherited disease, is known though not frequent. A case of familial cylindromatosis with parotid gland adenoma is herein reported. A 67-year-old lady presented with multiple scalp nodules and papular coalescent lesions over the nasolabial folds and the forehead. The clinical examination also revealed a left preauricular lump. Multiple biopsies of the scalp lesions and the nasolabial papules revealed cylindromas and trichoepitheliomas respectively. CT scan and FNA of the preauricular lump were suggestive of parotid gland adenoma. The patient underwent excision of the scalp cylindromas and total left parotidectomy. There is no evidence of recurrence after 4 years. The association of BSS with salivary gland tumours, emphasizes the necessity of thorough salivary gland examination in all patients with skin lesions. Knowledge of the genetic background of BSS allows for genetic counseling of patients.

Ulcerative locally advanced breast cancer: the efficacy of combined anthracycline-based and hormonal therapy

AIM

In the literature there are numerous large prospective studies on patients with locally advanced breast cancer, however little is reported on the management of ulcerative breast cancer. The aim of this study was to evaluate the employment of combined anthracycline-based chemotherapy and hormonal therapy in ulcerative locally advanced mammary carcinoma.

PATIENTS AND METHODS

Four patients, aged from 67 to 83 years, presented with ulcerative breast cancer resulting in breast destruction. Histological examination of biopsy specimens revealed highly differentiated estrogen receptor-positive ductal carcinomas. All tumours were classified as locally advanced since there was no clinical or radiologic evidence of distant metastasis in any of the patients. Due to their religious beliefs all patients refused any other treatment but chemotherapy. In these patients hemostasis and reduction of bacterial overgrowth were followed by administration of anthracycline-based chemotherapy and hormonal therapy.

RESULTS

All patients responded well; ulcer healing and partial remission were achieved for a period ranging from 19 to 28 months before disease progression.

CONCLUSION

There is clinical evidence from this study that the combination of anthracycline-based palliative chemotherapy coupled with tamoxifen is beneficial for patients with inoperable ulcerative breast cancer.