The combination of hyaluronic acid and collagenase in the treatment of skin ulcers: an open, multicenter clinical study assessing safety and tolerability of Bionect Start®

OBJECTIVE

Several clinical studies have shown that hyaluronic acid collagenase is well-tolerated and very effective in managing chronic venous ulcers. The aim of the present study is to confirm the safety and tolerability of daily application in patients suffering from cutaneous ulcers of different etiologies. The efficacy of the treatment and its impact on patients' quality of life are also assessed.

PATIENTS AND METHODS

Patients with a clinical diagnosis of skin ulcer with devitalized/fibrinous/slough tissue that could delay the healing process were enrolled in the study. The hyaluronic acid/collagenase ointment was applied topically until wound closure or total debridement of non-viable tissue was achieved, however, with a limit of 30 days. Monitoring was performed weekly, either through outpatient visits or telephone surveys. Assessments included adverse events, local irritation reactions, pain at dressing changes, and wound bed status. Patients were also requested to complete a quality-of-life questionnaire.

RESULTS

The study involved 96 patients with a mean age of 71 years. The patients suffered mainly from traumatic (21.9%), venous (15.6%), or pressure ulcers (12.5%); in 26% of cases, ulcers had mixed etiology. In approximately 32% of patients, the ulcer had been present for more than 6 months, and 18.1% of subjects had previously undergone surgical wound debridement.

CONCLUSIONS

Daily application of hyaluronic acid-collagenase achieved the following results: i) absence of adverse events related to the use of the product; ii) significant reduction in the degree of localized irritation and pain at dressing changes; iii) significant support to wound bed preparation; iv) trend towards improvement in the quality of life and health status of the patients.

The use of dermal regeneration template (Pelnac®) in a complex upper limb trauma: the first Italian case report

Dermal regeneration template (DRT) has been well widely implicated in the reconstruction of full-thickness injury. We present our experience and our clinical application of Pelnac® to achieve wound closure with complex acute, upper limb, full-thickness defect post-trauma. A 22-year-old boy presented a soft tissues loss of the back of the hand and forearm with tendon's involvement and exposure. The wound was treated with Pelnac®; the silicone layer was removed at postoperative day 30 and dermal regeneration template was reapplied at the level of the residual tendon exposure; a split-thickness skin graft (0.2 to 0.3 mm) was inserted. Clinically, the reconstructed areas demonstrated good granulation tissue at 14 days with a good take of the skin graft. There were no major acute graft loss, rejection or associated infections cells through downregulating TLR4 expression.

Depression risk among patients with chronic wounds

OBJECTIVE

A wound is defined as chronic when it requires more than 6 weeks to heal. The link between chronic wounds and depression was first pointed out by House and Hughes in 1996 and later evaluated by other numerous studies. Several studies demonstrate that among chronic skin wounds causing chronical physical disease, the leg ulcers are the most frequently associated with depression. The aim of our study is to evaluate the prevalence of depression in patients with different types of chronic wounds.

PATIENTS AND METHODS

We enrolled a total of 33 patients with chronic wounds and 33 healthy controls matched by sex and age. Both patients and controls underwent a BDI II survey. We evaluated 33 patients, with a mean age of 71 years (range 25-87), and 33 controls, with a mean age of 73 years (range 31-88).

RESULTS

The average score at the BDI II questionnaire was 14.5 and 8, respectively.

CONCLUSIONS

The depression among patients with chronic wounds has a multifactorial origin that should be treated with a multidisciplinary approach. Since the improvement of the psycho-emotional state means better compliance of the patient, we can also expect a better result in terms of efficacy in chronic wound treatment.

Axillary ectopic lobular carcinoma of breast: two rare case reports

OBJECTIVE

The presence of ectopic or supernumerary breast tissue is a rare event, related to a not complete regression of breast tissue along the milk line. Primary ectopic breast cancer of the axilla can create many difficulties in differential diagnosis with subsequent delayed specific treatments. The incidence of ectopic breast tissue is 0.2-6%, and the axilla is the most common site involved. In this tissue, the same physiologic and pathologic changes as seen in ectopic breast tissue may occur, including carcinoma formation.

PATIENTS AND METHODS

Two patients (a 56 years old and 70 years old women) came to our attention for the recent development painless nodular axillary lesions, clinically characterized by an increased thickness, irregular margins and adherence to the floors below.

RESULTS

Patients underwent ultrasonography (US) and mammography (MMG) revealing non-specific features of the lesions. Magnetic resonance imaging (MRI), demonstrated margins slightly irregular and a non-specific appearance of each lesion. Both patients underwent wide local excision with axillary lymph node dissection. Histological examination showed infiltrating lobular carcinomas of the breasts.

CONCLUSIONS

We describe two unusual cases of ectopic axillary breast carcinoma localization. It is important a correct and fast diagnosis with a local examination, diagnostic instruments, surgical excision and histological examination.

Breast reduction: personal technique

INTRODUCTION

Macromastia is a health problem that requires the coordination of surgical and medical specialists. Goals of reduction mammaplasty are to alleviate physical, emotional and psychosocial discomforts and to restore a conical-shaped breast, maintaining scars as short as possible. We report our approach for reduction mammaplasty with superior pedicle.

MATERIALS AND METHODS

Our method combines advantages of round block with vertical scar, using a dermal flap that is fixed to the new mammary crease. We analyzed skin and glandular resection customizing the mammaplasty.

RESULTS

The dermal flap works against the weight of residual tissue, maintaining the crease at the desired position with a natural result. Benefits are an excellent projection, short scar, suitable reshaping and patient satisfaction.

CONCLUSIONS

This technique can be used for mild to severe hypertrophy with various degrees of ptosis. It results in a successful aesthetic outcome with minimal scarring, suitable breast remodeling and natural long-lasting projection.

New lift: the art of facial rejuvenation with minimal incisions rhytidectomy

OBJECTIVE

The new lift is a procedure for facial rejuvenation with minimal incision, giving the patient a significant improvement of mid face and neck, with limited dissection and minimal scars. A further "One-stitch" of anchorage to the deep temporal fascia is required to hold tissues. By a minimal surgical access, we get a suitable cheek lift with the improvement of nose-labial folds, mandibular edge and neck contour.

PATIENTS AND METHODS

Between February 2009 and June 2012, 32 patients underwent facial rejuvenation surgery called new lift at a mean age of 46 years (range 35-55 years). Seven of the patients had a previous facelift. 12 out of 32 patients (37.5%) had concomitant eyelid surgery and 4 (12.5%) neck contouring procedure.

RESULTS

The technique we used is a safe and effective procedure with a high satisfaction rate; 28 patients (89%) were very satisfied with their result at 24-months follow-up.

CONCLUSIONS

The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. Aesthetic results were evaluated also by patients themselves who indicated a high satisfaction rate at three months post-surgery questionary and by a surgeon not involved in the study using VAS (1-10) before and three months after surgery. Acquired data on the aesthetic result were statistically evaluated using Student t-test. This is a study aimed at assessing the effectiveness of the new-lift technique for facial rejuvenation. Based on the results of our study, the new-lift is a very effective surgery for rejuvenation of the face with mild to moderate aging. All patients healed uneventfully without any major postoperative problems. This technique responds to an increasing demand from a wide range of patients for less invasive, less expensive operations with faster healing time and fewer potential complications.

Surgical therapy of breast hypertrophy: a comparison of complications and satisfaction rate in large and small superior pedicle custom-made reduction mammaplasty

OBJECTIVE

The reduction mammaplasty is indicated for patients with symptomatic breast hypertrophy. Although surgery is considered the gold standard treatment, it is still debated which is the complication rate and whether or not there is an increased complication rate with increased tissue resection per breast. The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (≥2000 g per breast) as compared with smaller reductions (≤1999 g per breast) using the superior pedicle custom-made technique.

PATIENTS AND METHODS

A retrospective study of 90 consecutive operated patients was performed. All the patients underwent a bilateral breast reduction for macromastia. 43 patients had a reduction of 1999 g or less and 47 patients had a reduction of 2000 g or more.

RESULTS

There were no statistically significant differences in the rates of nipple necrosis, hematoma, seroma, wound dehiscence, wound infection, loss or reduction of nipple sensation, and a pathologic scar between the large and small resections.

CONCLUSIONS

The large reduction patients pointed higher mean satisfaction rate than the small reduction patients. The superior pedicle custom-made technique is a safe method of breast reduction regardless of the degree of parenchymal resection, achieving a successful aesthetic outcome with minimal scarring and high satisfaction rate for both small and large breast reduction.

Patient satisfaction as an excellent track record in nonsurgical rejuvenation procedures

OBJECTIVE

Patient satisfaction is the goal of most aesthetic procedures. The aim of this study is to analyse nonsurgical rejuvenation procedures in a private practice setting, over a period of 10 years, evaluating patients' compliance, satisfaction and maintenance of a good fiduciary link with the medical operator.

PATIENTS AND METHODS

A retrospective study was performed on 429 patients who received nonsurgical rejuvenation procedures. Four types of treatments were considered: Botulinum toxin type A injections, Hyaluronic acid or Poly-L-lactic acid injections, and a combination therapy. The outcome analyzed included a number of patients for each treatment for each year, the treatment time interval, the number of treatments for each patient, the number of treatments according to facial sub site and the "degree of satisfaction".

RESULTS

The most required treatment was combination therapy (36.8% of patients). The mean time and the median time of permanency in the study were respectively 19 and 6 months. After 18 months, which is the time that we considered to attest a good "degree of satisfaction", 55% of patients were still in the study. Patients with only one treatment were excluded.

CONCLUSIONS

The study findings support evidence of a more recently described increase in popularity in minimally invasive aesthetic procedures, of which combination therapy has the best performances with a good degree of satisfaction.

Upper lip reconstruction and aesthetic aspects in the female patient: our point of view

Brief title: A brief description of our point of view about upper lip reconstruction supporting a quite simple and effective surgical option, which surgeons could consider whenever little neoformations must be removed from the lips, an aesthetically important anatomical region.

Bilateral hand squamous-cells carcinoma in patient affected with non-Hodgkin lymphoma. Case report and literature review

BACKGROUND

Squamous-cell skin cancer is the most frequent tumor in the hand. It occurs on sun-damaged skin, especially in lightskinned individuals with a long history of chronic sun exposure.

CASE REPORT

We describe a case of bilateral hand squamous-cell carcinoma in a elderly patient affected with non-Hodgkin's lymphoma, who underwent several non-successful surgical treatment, radiotherapy and at the least, amputation of right hand for rapid clinical evolution after radiotreatment. Available literature on the subject has been reviewed.

RESULTS

In our case, after several non-successful treatment, elective amputation at the distal third of forearm was performed. We reviewed 56 items including books, original articles, reviews, cases report.

CONCLUSIONS

Current evidence on treatment of hand squamouscells carcinoma is to perform a first radical surgical treatment in order to avoid recurrence/metastasis and to achieve a safer level of amputation thus increasing the surface area of healthy tissue available for eventually subsequent reconstruction/prosthesization.

Caustic burn caused by intradermal self administration of muriatic acid for suicidal attempt: optimal wound healing and functional recovery with a non surgical treatment

BACKGROUND

Caustic burns are burns of third and fourth degree caused by strong acids or strong bases. Muriatic acid is often used for suicidal attempt by ingestion. We describe a case of a caustic skin lesion caused by intravenous failed attempt of suicide by injection of Muriatic acid in a woman affected with bipolar-syndrome. Generally, caustic burns are treated by cleansing, escarectomy and coverage with skin grafts.

CASE REPORT

We treated the patient with a non invasive technique with collagenase and hyaluronic acid sodium salt cream (Bionect start®), hyaluronic acid-based matrix (Hyalomatrix®) and Vacuum-Assisted Closure (VAC) Therapy®.

RESULTS

We obtained complete healing in 6 weeks.

CONCLUSIONS

Combined use of non invasive techniques seems to ensure only advantages for both the patients and the Health System. It reduces health care costs and risks for the patients such as nosocomial infections. Patient's compliance is high, as its quality of life. Complete healing of the wound is fast and recovery of function is full.

The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity

INTRODUCTION

Muscles of the nose are active in facial movements both with the other facial muscles. An active depressor septi muscle (DSN) can accentuate a drooping nasal tip and shorten the upper lip on animation, especially during smiling. Paralysis of the DSN allows the tip of the nose to be lifted up.

MATERIALS AND METHODS

Between January and June 2011 a double blinded, randomized study was performed on 40 patients for nasal defects as "plunging" tip. 20 patients underwent to Botulinum toxin injection (B), 20 patients were treated with placebo such as saline solution (S). Both aesthetic and functional results were evaluated using objective and subjective parameters at time 0, after 7, 15 and 30 days and values were compared using t Student test.

RESULTS

S group results were not significant from an objective point of view. In botulinum group, patients showed an increase in columellar-lip distance. Satisfaction of the Group B patients was an average of 6.3 on VAS (range from 4 to 9). VAS mean values were studied with t-Student test and were found significant.

DISCUSSION

Several authors recommend the incision of DSN muscle during rhinoplasty to correct the plunging tip. In patients with no needs for rhinoplasty this procedure is unnecessary and a quick and targeted injection of Botulinum toxin is the most convenient choice to improve aesthetic of the plunging tip.

[Inveterate squamous cell carcinoma of the upper eyelid: a case report]

Squamous cell carcinoma (SCC) is a malignant tumor of epithelium that shows squamous cell differentiation. It is the second most common cancer of the skin and usually occurs in areas exposed to the sun but it can rarely arise within the conjunctival epithelium with a deep component. We describe a woman with a history of chronic blepharoconjunctivitis unresponsive to topical medications. Examination disclosed a hyperaemic translucent patch with blurred margins of the upper palpebral conjunctiva. Tarsoconjunctival biopsy revealed intraepithelial squamous cell carcinoma. Management consisted of complete tumor excision with removal of the entire posterior lamella of the left upper eyelid and reconstruction. Histopathologic analysis confirmed primary squamous cell carcinoma arising from conjunctival epithelium, involving the underlying tarsus. Patients with unexplained chronic unilateral blepharoconjunctivitis or papillary hypertrophy of the palpebral conjunctiva should be considered for biopsy to rule out neoplasia, even when there is no sign of an evident mass.

A new association between hyaluronic acid and collagenase in wound repair: an open study

BACKGROUND

Most ulcers occur with slough and need debridement treatment. Surgical treatment is usually performed but many patients need an additional chemical therapy to promote healing process. This type of wound bed preparation is slower than surgical one, but it is essential in those patients who are not eligible for surgery because of systemic diseases. A collagenase derived from the bacterium Clostridium hisolyticum is the most used.

AIM

To evaluate the safety and the effectiveness of a new collagenase produced by Vibrio algynoliticum.

MATERIALS AND METHODS

Forty patients were enrolled and daily treated for five weeks with Bionect Start® ointment. Parameters took into account were fibrin degradation and pain relief. The same team carried out treatment during the study period of five weeks.

RESULTS

32 patients achieved a relevant reduction of the ulcer size, an improvement of the wound bed and a reduction of fibrin and exudates. Among of 32, 14 patients presented with a complete healing. Eight patients had mild or no improvements. The patients referred a remarkable pain reduction, 20 out of 40 patients reported a decrease in pain during treatment, 16 patients referred no pain at all and four patients had no significant changes.

CONCLUSIONS

The application of this product on the lesions promotes vascularized granulation tissue and reduces formation of fibrin and exudate. Furthermore, a macroscopical margins proliferation is highlighted after a short time and an improvement of periwound skin is observed during the treatment period. Bionect Start® allowed easy removal of dressing, less pain for patient, reduction of dressing time.

Masson's tumor: a soft tissue tumor simulating a tendon cyst: case report

INTRODUCTION

Intravascular papillary endothelial hyperplasia (Masson's hemangioma or Masson's tumor) is a benign vascular disease with an exuberant endothelial proliferation in normal blood vessels. Although relatively uncommon, its correct diagnosis is important because it can clinically be like both benign lesions and malignant neoplasms. We present a case of intravascular proliferative endothelial hyperplasia simulating a tendon cyst both clinically and on ultrasound.

CASE REPORT

A 74-year old Caucasian female presented with a 4-month history of soreness and swelling in the fourth finger of the right hand. Ultrasound showed an oval mass with fluid content, referred to a tendon cyst. A wide surgical excision was subsequently performed. The final histological diagnosis was Masson's tumor.

DISCUSSION

The pathogenesis of intravascular papillary endothelial hyperplasia is still unclear but the exuberant endothelial cell proliferation might be stimulated by an autocrine loop of endothelial basic fibroblast growth factor (bFGF) secretion. There are three types of papillary endothelial hyperplasia: primary, or intravascular; secondary, or mixed; and extravascular. The main differential diagnosis is against pyogenic granuloma, Kaposi sarcoma, hemangioma, and angiosarcoma.

CONCLUSIONS

Masson's tumor can be like both benign lesions and malignant neoplasms clinically and on ultrasound. For this reason, the right diagnosis can be made only by histology, which reveals a papillary growth composed of hyperplastic endothelial cells supported by delicate fibrous stalks entirely confined within the vascular lumen.

Comparative analysis between nasolabial and island pedicle flaps in the ala nose reconstruction. Prospective study

The goals of reconstructing deformities of the face secondary to skin cancer include reconstructing the area with similar tissue. The comparison between different types of local flaps for reconstruction of nasal ala is presented in a prospective, randomized study. The objective of this study was to compare the functional and esthetic outcomes between the nasolabial and island flaps. A total of 60 patients with skin cancer of the nose underwent ala reconstruction: 30 cases by nasolabial flap (group A) and 30 by island flap (group B). The two groups were homogeneous for sex, age, and anatomical area. Complications, scarring according to the scale of Vancouver, cosmetic appearance, and disorders of sensations were analyzed and statistical analysis was performed. In group A, early complications were more common than in group B. The scars of group B patients were more like those of undamaged skin. A total of 10% patients of group A evaluated the cosmetic appearance of their nose as very good, while in group B, 30% patients gave such an evaluation. Local flaps provide better reconstruction and the island flap appears to have more efficacy when compared with nasolabial flap for nasal ala reconstruction.

Fibroepithelioma of Pinkus: variant of basal cell carcinoma or trichoblastoma? Case report

INTRODUCTION

Fibroepithelioma of Pinkus (FeP) is a rare tumor that most often affects women aged between 40 and 60 years. Clinically FeP presents as a soft, usually solitary, polypoid or papillomatous well circumscribed tumor of skin color. It is typically located to the trunk and extremities.

CASE REPORT

A 75 year old male presented to our Department complaining for the presence of a lesion of the dorsal region. His medical history was free except for several basal cell carcinoma (BCC) surgically excised. Clinical examination revealed a pigmented lesion in the back. The lesion was surgically excised and histopathology showed of a fibroepithelioma of Pinkus.

DISCUSSION

Currently, FeP is considered a rare variant of basal cell carcinoma, with characteristic histopathological features, although this view is somewhat controversial as some authors considered FeP to be a variant of trichoblastoma. The pathogenesis of FeP is still under investigation. It is thought that a mutation in the tumor suppressor gene TP53 might predispose to the development of FeP.

CONCLUSIONS

Our case is interesting for two reasons. First, in our case FeP is pigmented. Moreover we present a case of Fep in a patient with a history of BCC, a finding that supports the classification of fibroepithelioma of Pinkus as a variant of basal cell carcinoma.

Neuro-ocular cutaneous syndrome: a case report

Neuro-ocular cutaneous syndrome is a rare and little-known illness. It affects the ocular apparatus, the nervous system and the skin. The disease causes pathologies such as phacomatosis, which is a generic term used to describe small cutaneous neoformations, as well as other ectodermal organ malformations (ocular apparatus and central nervous system). The symptoms of this disease are ocular, neurological and dermatological and can include: corneal opacity, papillary coloboma, optical atrophy, epibulbar dermoids, corectopia, palpebral coloboma, frontoparietal alopecia, epilepsy, psychomotor delay, pedunculated skin growths, a yellowing of the frontal area, milled papules, milled patches of skin, cutaneous spotting, familial angioma and hemiplegia. Due to the complexity of this disease, it is imperative that specialists (including ophthalmologists, neurologists, dermatologists, plastic surgeons, pediatricians and genetics) examine a great number of families affected by this rare pathology in a precise, accurate and ongoing manner. The clinical case of a 15 year-old patient (who was diagnosed at 10 months old) affected by the neuro-ocular cutaneous syndrome will be discussed below.

Antibiotic therapy of transaxillary augmentation mammoplasty

BACKGROUND

Capsular contracture is the most common complication and the main cause of dissatisfaction after augmentation mammoplasty, for both the patient and the plastic surgeon. The formation of fibrous tissue around the prosthesis alters the form or the consistency of the implant, thus modifying the breast shape, its contour and its softness. The initial satisfaction with the achieved aesthetical result is then transformed into great dissatisfaction, due to the presence of a shapeless and undesired mass.

PATIENTS AND METHODS

The following study considered data collected between 1998 and 2007. Sixty-seven female patients (aged between 35 and 53 years) who suffered from mammary hypotrophy and had undergone submuscular augmentation mammoplasty were enrolled. All the implanted prostheses were round and texturized, with a volume of 250 cm3 to 450 cm3. The patients underwent pre-, intra- and postoperative antibiotic therapy in order to prevent clinical and subclinical infection of the implants.

RESULTS

The follow-up ranged from a period of two to nine years. All patients were examined during the first antibiotic administration and again subsequently, after 1, 3, 6 and 12 months, to evaluate the results in terms of capsular contracture. Of all patients, 90% presented a degree I Baker's classification, the remaining 10% a degree II. Not one of the patients treated showed grade III or IV capsular contracture nor was there any need to remove the prosthesis during the examination period.

CONCLUSION

It is clear that a main role in capsular contracture is played by the infectious process, with the activation of specific inflammatory cells. Interfering with the infectious process can prevent fibrotic reaction evolving into capsular contracture. Although the process causing capsular contracture is multifactorial, our study showed a favourable response can be achieved when using antibiotic therapy associated with the transaxillary approach.

[New therapeutic strategies for the treatment of difficult wounds]

BACKGROUND

The medical-surgical treatment of the difficult wounds represents a socio-sanitary problem in continuous growth, currently involving in our Country around 2,000,000 people. The "difficult wound" is a loss of cutaneous substances, usually due to multifactorial pathogenesis, that do not spontaneously lead to a complete recovery. Numerous studies in the literature have evidenced that the use of the advanced wound dressings allows to reach the best clinical and economic results in the process of recovery of the difficult wounds. The advanced would dressing assures a longer period of permanence on the injury and shorten the time of treatment and, as a consequence, it is required a smaller number of applications in comparison with the traditional medications. The Wound Bed Preparation (WBP) can be defined as the global and coordinate management of the cutaneous injury, enabling to chip off the local barriers to the recovery, or promoting the effectiveness of the innovative therapeutic instruments. The term advanced wound dressing indicates the dressing material having biocompatibility characteristics. The purpose of the advanced wound dressings is the one to create the ideal environment for the cicatrization process and isolate the wound from traumas and external infections.

PATIENTS AND METHODS

The "Difficult Wounds" Unit of the Department of Plastic and Reconstructive Surgery of the Policlinico Umberto I in Rome, from January to December 2006, treated 570 patients (308 men and 262 women), whose age was between 2 days and 85 years, affected by ulcers of various nature. Among our cases, 200 patients were selected and randomly separated in two different groups: group A consisting of 100 patients entirely treated with traditional medications; group B composed by 100 patients treated with advanced dressings. Every patient has locally been treated with periodic and specific medications, according to the type of difficult wound, and subsequently they proceeded to find out how to treat the systemic factors causing ulcer. The patients underwent 3 times a week to medications in those cases presenting infection signs and 2 times a week in those cases where no infection signs were shown, for period varying from 1 month up to one year for the chronic forms.

RESULTS

The results showed a higher percentage of recovery reached by using the advanced dressings. Group A showed the followings results: the 53% of patients recovered from wounds; the remaining 47% patients did'nt not recover but in 17% cases medications showed to be of some help in the preparation of the vascular bed for the execution of a definitive operation (application of grafts or local edges), while the remaining 30% has shown a scarce improvement of the injury and they are still under treatment. Group B showed the 65% of patients recovered from wounds; as for the remaining 35% not recovered patients, medications represented an auxiliary aid to the preparation of the vascular bed for the execution of a definitive operation (application of grafts or local edges) for the 15% of patients, while the remaining 20%, even if not completely recovered, showed a notable improvement of the injury (reduction of the dimensions and disappearance of the infection and improvement of the patient quality of life).

CONCLUSIONS

In synthesis, it emerges that the advanced dressings, if correctly used, offer advantages in terms of clinical effectiveness (rapid recovery from the injury), patient quality of the life and cheapness. It has also to be considered that the difficult wound is often the epiphenomenon of a systemic illness. The difficult wound requires, therefore, a multidisciplinary treatment.