Abstract: INTRODUCTION:: Neuroma formation is a major problem in nerve surgery and consensus about its prevention has not been reached. It has been suggested that vein covering can reduce neuroma formation in transected nerves. In this article, the Authors propose an easy and novel method of covering by nerve stump capping with a free vein graft. METHODS:: Neuroma-like lesions were created on the rat thigh sectioning the femoral nerve above its division in 16 animals. The proximal nerve stump was invaginated into the lumen of a 1.5 cm long femoral free vein graft on the right side, and the vein was closed on itself by microsurgical sutures to form a cap for the nerve stump. On the left side acting as the control neuroma, the nerve was cut and left uncovered. Histological and immunohistochemical assessment was used to quantify the degree of neuroma formation. RESULTS:: Significant differences were found in both neuroma size and axon-glia organization between the treated and control sides indicating that free vein graft capping reduced neuroma formation in comparison to uncovered nerve stumps. CONCLUSIONS:: Our results confirm that vein-covering of a transected nerve stump can be effective in reducing neuroma formation. Moreover, unlike previous works that buried the nerve into an adjacent vein left in place, our experiments showed that also the use of a free vein graft cap can hinder neuroma formation. Although translation of rat experiments to the clinics should be dealt with caution, our data suggest a careful clinical use of the technique. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.
Abstract: A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76-year-old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior-lateral thigh perforator flap was successfully transferred with end-to-side anastomoses on the arterialized venous graft. Up to date follow-up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.
Abstract: BACKGROUND: Squamous cell carcinoma (SCC) is the second most common skin cancer in humans. Because the incidence of metastasis from SCC of the skin is rare, regional lymphadenectomy is generally not recommended for the patients with clinically node-negative disease. However, in patients with an intermediate and high risk of metastasis, evaluation of the lymph nodes to detect the absence of metastatic nodal disease is a difficult task. PATIENTS AND METHODS: The authors reviewed the pertinent demographic and surgical data in a consecutive series of six patients with squamous cell carcinoma who underwent sentinel lymph node staging. The tumour size was greater than 2 cm (T2) and the patients had clinically non-palpable regional lymph nodes (N0). All nodes were examined using haematoxylin-eosin staining. Sentinel Lymph Node Biopsy (SLNB) and Selective Lymphadenectomy (SL) using preoperative lymphoscintigraphy and intraoperative radiolymphoscintigraphy and vital dye injections was used to identify the sentinel lymph node avoiding complete axillary node dissection. RESULTS: No false-negative results were observed. At a median follow-up of 10 months (mean 15 months), neither local or regional recurrences in sentinel node-negative basins have been noted. Conclusions: Sentinel node biopsy is a minimally invasive staging procedure useful in identifying occult regional lymph node disease in selected patients with squamous cutaneous malignancies of the arm. Furthermore sentinel lymph node histology is possibly the most important negative predictor of early recurrence and survival in patients with American Joint Committee on Cancer stage I and II squamous cell carcinoma. Although sentinel node-negative patients are a prognostically favourable group, this small series of patients demonstrates that further studies to verify these findings and develop formal guidelines are indicated
Abstract: BACKGROUND: Microsurgical tissue engineering is an emerging topic in regenerative medicine. Here we describe a new microsurgical model of bioengineering in rats based on the use of an arterovenous loop (AV) implanted into a commercially available crosslinked collagen/glycosaminoglycan template. METHODS: The microvascular loop was created between the femoral artery and vein and covered by the template folded onto itself. The chamber was isolated from the outside tissue by an outer silicon layer to impede tissue ingrowth. RESULTS: At 1-month postimplantation, the tissue chamber was found heavily vascularized, as assessed by laser Doppler perfusion analysis. Histological examination showed that the AV loop was integrated into the collagen matrix of the template and that the whole template was filled with a newly formed soft connective tissue. Most interestingly, the whole scaffold was found heavily vascularized, including the formation of a large number of alpha-SMA-positive arterioles. CONCLUSIONS: The developed microsurgical chamber provides a highly vascular, isolated tool for in vivo tissue engineering.
Abstract: INTRODUCTION: Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills. Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated in the region of lateral malleolar gutter. PATIENTS AND METHODS: Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular ulcers, osteomyelitis and oncological resection. Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency of peroneal axis and associated morbidity that could increase risk offlap necrosis. This included diabetes mellitus type II, osteomyelitis and peripheral arterial diseases. RESULTS: All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the skin island. All defects were covered with no major complications and none of the patients required a blood transfusion. Moreover aesthetic results were good with satisfaction of all the patients. CONCLUSION: In our cases we found the sural reverse flap to have a good reliability with low incidence of complication and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in patients with associated pathology as vascular diseases or diabetes.
Abstract: Topical negative pressure (TNP) has been introduced in complex surgical reconstruction and difficult wound healing, having proven to be effective in both drainage of wound secretions and calling for a new, sterile granulating tissue. In the last 15 years many reports have been focusing on TNP in different surgical specialties (orthopedic surgery in exposed fractures, general surgery in eventration, cardiothoracic surgery in sternal dehiscences, plastic surgery in difficult wounds and pressure sores). The authors report their personal experience being among the first Units to use TNP systematically in Italy.
Abstract: We investigated the effects of raxofelast, a lipid peroxidation inhibitor, in an experimental model of burn wounds. C57BL/6 male mice of 25-30 g were immersed in 80 degrees C water for 10 seconds to achieve a partial-thickness scald burn. Animals received intraperitoneally either raxofelast (20 mg/kg/day for 14 days in 100 microL) or its vehicle alone (100 microL/day for 14 days). On day 14, burn areas were used for measuring conjugated dienes, reduced glutathione levels, histological damage, neoangiogenesis by immunohistochemistry and expression (Western blot) of the specific endothelial marker CD31 as well as quantification of microvessel density, VEGF wound content, endothelial and inducible nitric oxide synthase (eNOS and iNOS) expression and wound nitrite content. Raxofelast decreased tissue conjugated dienes (vehicle 6.1 +/- 1.4 DeltaABS/mg protein; raxofelast 3.7 +/- 0.8 DeltaABS/mg protein), prevented tissue glutathione consumption (vehicle 3.2 +/- 0.9 micromol/g protein; raxofelast 6.7 +/- 1.8 mumol/g protein), increased epithelial proliferation, extracellular matrix maturation, and augmented neoangiogenesis as suggested by the marked increase in microvessel density and by the robust expression of the specific endothelial marker CD31 (vehicle 9.4 +/- 1.1 integrated intensity; raxofelast 14.8 +/- 1.8 integrated intensity). Furthermore, raxofelast enhanced VEGF wound content (vehicle 1.4 +/- 0.4 pg/mg protein; raxofelast 2.4 +/- 0.6 pg/mg protein), caused a marked expression of eNOS (vehicle 16.1 +/- 3 integrated intensity; raxofelast 26.2 +/- 4 integrated intensity) and iNOS (vehicle 9.1 +/- 1.8 integrated intensity; raxofelast 16.2 +/- 3.5 integrated intensity) and increased wound nitrite content. Lipid peroxidation inhibition by raxofelast may be an effective therapeutic approach to improve clinical outcomes after thermal injury.
Abstract: The aim of this study was to review the surgical anatomy and the variants of the orbicularis oculi myocutaneus flap (OOMF) for reconstruction of inner canthus defects. Anatomic studies in fresh heads were carried out to demonstrate its blood and nerve supply. Four cases of epitheliomas of the inner canthus were treated with surgical excision and reconstructed with medially based island and nonisland OOMF. A 36-months follow-up showed no deformities of the flap, good colour matching and satisfaction scars. The flap is recommended for small to medium size defects of the inner canthus in patient with skin excess in the eyelid.
Abstract: BACKGROUND: Prevention of adhesions that restrain tendon gliding is based on early mobilization techniques. Such approach, anyway, does not guarantee positive outcomes. METHODS: Seventy-five patients for a total number of 98 flexors tendons have been treated at the University Hospital of Messina between December 1993 and January 2000. Twenty-five patients, for a total number of 26 tendons, have been seen at follow-up. Seventeen lesions involved zone 2 and 9 involved zone 1.The modified Kessler suture has been generally used. All the repairs have been followed by an adequate early mobilization protocol, according to Kleinert (passive extension/active flexion) in nine patients and according to Risitano and Savage (active extension/active flexion) in 16. RESULTS: Minimum follow-up was 12 months. We present results with an assessment performed according to Strickland and to Elliot for lesion in zone 1 and according to Strickland and using Total Active Motion of the finger for lesions in zone 2. CONCLUSIONS: The suturing technique and mobilization protocol did not affect results, but we made some considerations about respective advantages and disadvantages of either method.
Abstract: OBJECTIVE: The purpose of this study was to investigate the effect of recombinant adeno-associated viral (rAAV) vector-mediated human vascular endothelial growth factor (VEGF165) transfer on experimental burn wounds. DESIGN: Randomized experiment. SETTING: Research laboratory. SUBJECTS: C57BL/6 male mice weighing 25-30 g. INTERVENTIONS: Mice were immersed in 80 degrees C water for 10 secs to achieve a partial-thickness scald burn. Animals were randomized to receive at two injection sites on the edge of the burn either 1011 copies of the rAAV-VEGF165 or the vector carrying the control and inert gene beta-galactosidase (rAAV-LacZ). On day 14 the animals were killed. Burn areas were used for histologic examination, evaluation of VEGF expression (immunohistochemistry) and VEGF wound content (enzyme-linked immunosorbent assay), determination of wound nitrite, and measurement of messenger RNA (mRNA) for endothelial and inducible nitric oxide synthase (eNOS and iNOS). MEASUREMENTS AND MAIN RESULTS: rAAV-VEGF165 increased epithelial proliferation, angiogenesis, and maturation of the extracellular matrix. Furthermore, gene transfer enhanced VEGF expression, studied by immunohistochemistry, and the wound content of the mature protein (rAAV-LacZ, 11 +/- 5 pg/wound; rAAV-VEGF165, 104 +/- 7 pg/wound). Moreover, VEGF165 gene transfer increased wound content of nitrate. Finally, rAAV-VEGF165 administration enhanced the messenger RNA for eNOS (rAAV-VEGF165, 1.1 +/- 0.2 relative amount of eNOS mRNA; rAAV-LacZ, 0.66 +/- 0.3 relative amount of eNOS mRNA) and iNOS (rAAV-VEGF165, 0.8 +/- 0.09 relative amount of iNOS mRNA; rAAV-LacZ, 0.45 +/- 0.05 relative amount of iNOS mRNA). CONCLUSION: Our study suggests that rAAV-VEGF gene transfer may be an effective therapeutic approach to improve clinical outcomes after thermal injury.
Abstract: AIMS: To investigate demographics, modalities and type of injuries among a population of isolated traumatic injuries of extensor tendons in order to evaluate the consequences on health service and on prevention. METHODS: Retrospective study of injuries treated at the divisions of Plastic Surgery and Orthopedics in a third level referral center among the years 1993-1999. MAIN RESULTS: Data from 173 patients were analyzed, a prevalence of males (81%) and injuries at home (55%) has been observed. Especially young adults (46.88%) have been involved, the thumb has been most interested finger and the middle finger the least, with two peaks of incidence in spring and autumn. The lesions, exposed through an extension of the existing wound, have been usually sutured according to Kessler, adding an early protected motion protocol. CONCLUSIONS: We discuss the possible causes and consequences of data observed, with special reference to the possibility of treating isolated extensor tendon injuries at district hospitals by non-hand surgeons, and primary actions of prevention.
Abstract: Basal cell carcinoma (BCC) is the most common skin malignancy arising from cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. BCC of the digit is a rare entity. The article presents one such case of bowenoid BCC of the thumb which required amputation at the MP joint.
Abstract: Lateral malleolus avulsion is uncommon, and fusion of the syndesmosis of the ankle joint is usually performed in such cases. Others have reported successful reconstruction of the lateral malleolus with a vascularized fibular head. A case of reconstruction in a 17-year-old girl, with a free scapular apophysis flap, is presented and compared with alternative flaps available. The anatomy and development of the scapular crest with its cartilaginous apophysis are discussed.
Abstract: BACKGROUND. Impaired wound healing is a well-documented phenomenon in experimental and clinical diabetes. Emerging evidence favors the involvement of free radicals in the pathogenesis of diabetes-related healing deficit. This study assessed the effect of systemic administration of raxofelast, a protective membrane antioxidant agent, on wound healing by using healing-impaired (db/db) mice. METHODS. The wound healing effect of raxofelast was investigated by using an incisional skin-wound model produced on the back of female diabetic C57BL/KsJ db+/db+ mice and their healthy littermates (db+/+m). Animals were then randomized to the following treatment: raxofelast (15 mg/kg/d intraperitoneally) or its vehicle (dimethyl sulfoxide/sodium chloride 0.9%, 1:1, vol/vol). The animals were killed on different days, and the wounded skin tissues were used for histologic evaluation and for analysis of malondialdehyde (MDA) level and myeloperoxidase (MPO) activity, wound breaking strength, and collagen content. RESULTS. Diabetic mice showed delayed wound healing together with low collagen content, breaking strength, and increased MDA levels and MPO activity when compared with their healthy littermates. The administration of raxofelast did not modify the process of wound repair in healthy (db/+) mice, but significantly improved impaired wound healing in diabetic mice through the stimulation of angiogenesis, reepithelialization, synthesis, and maturation of extracellular matrix. Furthermore, raxofelast treatment significantly reduced MDA levels, MPO activity, and increased the breaking strength and collagen content of the wound. CONCLUSIONS. The current study provides evidence that raxofelast restores wound healing to nearly normal levels in experimental diabetes-impaired wounds and suggests that an increased lipid peroxidation in diabetic mice may have a role in determining a defect of wound repair.
Abstract: Impaired wound healing is a well-documented phenomenon in experimental and clinical diabetes. Experimental evidence suggests that a defect in vascular endothelial growth factor (VEGF) regulation might be associated with wound-healing disorders. We studied the involvement of lipid peroxidation in the pathogenesis of altered VEGF expression in diabetes-related healing deficit by using an incisional skin-wound model produced on the back of female diabetic C57BL/KsJ db+/ db+ mice and their normal (db+/+m) littermates. Animals were then randomized to the following treatment: raxofelast (15 mg.kg(-1).day(-1) i.p.), an inhibitor of lipid peroxidation, or its vehicle (DMSO/NaCl 0.9%, 1:1 vol: vol). The animals were killed on different days (3, 6, and 12 days after skin injury), and the wounded skin tissues were used for histological evaluation, for analysis of conjugated dienes (CDs), as an index of lipid peroxidation and wound breaking strength. Furthermore, we studied the time course of VEGF mRNA expression throughout the skin-repair process (3, 6, and 12 days after skin injury), by means of reverse transcriptase-polymerase chain reaction, as well as the mature protein in the wounds. Diabetic mice showed impaired wound healing with delayed angiogenesis, low breaking strength, and increased wound CD content when compared with their normal littermates. In healthy control mice, a strong induction of VEGF mRNA was found between day 3 and day 6 after injury, while no significant VEGF mRNA expression was observed at day 12 after injury. In contrast, VEGF mRNA levels, after an initial increase (day 3), were significantly lower in diabetic mice than in normal littermates, and light induction of VEGF mRNA expression was also present at day 12 after injury. Similarly, the wound content of the angiogenic factor was markedly changed in diabetic mice. Administration of raxofelast did not modify the process of wound repair in normal mice, but significantly improved the impaired wound healing in diabetic mice through the stimulation of angiogenesis, re-epithelization, and synthesis and maturation of extracellular matrix. Moreover, raxofelast treatment significantly reduced wound CD levels and increased the breaking strength of the wound. Lastly, the inhibition of lipid peroxidation restored the defect in VEGF expression during the process of skin repair in diabetic mice and normalized the VEGF wound content. The current study provides evidence that lipid peroxidation inhibition restores wound healing to nearly normal levels in experimental diabetes-impaired wounds and normalizes the defect in VEGF regulation associated with diabetes-induced skin-repair disorders.
Abstract: The umbilicus is a rare site for malignant melanoma. We report two cases of umbilical melanoma and analyse the mechanisms of diffusion of the neoplasm in relationship to the arterial, venous, and lymphatic anatomy of the region. Because of the peculiarity of these connections, we propose a revision of the concept of melanoma stage for the umbilical region.
Abstract: Studies have been underway since 1981 on the scapular anatomic unit as a new donor site for reconstructive surgery. Anatomic studies have proven that this diaphyseal bone has a large osteocartilaginous growth epiphysis at its inferior pole, which is responsible for development of 80% of the surface of the scapula. Experimental investigations and clinical studies have revealed minimal functional limitation because of loss of the scapular crest and that its growth plate can be used beneficially for vascularized bone transfer. Four cases are reported with good results based on 2 to 14 years followup without significant impairment of the donor site.
Abstract: The authors analysed the advantages and drawbacks of the legislative rules in the Italian medical services. They underline the impediments to the improvement in the quality and efficiency of both the organizing models and the control system of administration. The authors consider a new trend in the administration system taking place in the most innovative and dynamic units and they analyze the efficacy and speediness of diffusion of this new system. The new model could be extended to the ASL and Hospital as a possible improvement of the present situation. The article is structured in two main parts; in the first one the legal changing, that took place in the last year, in the organization of the national medical system is critically examined; the second one summarized the most significant innovation brought by the new administrative system of ASL and hospital.
Abstract: Gynaecomastia is a disease with a high incidence (approximately 65% of adult males between 15 and 40 Ys.). In this paper the authors present their experience about the medical and surgical treatment comparing different surgical techniques: adenomammectomy, liposuction and liposuction associated with adenomammectomy. 61 patients ageing 17-42 Ys. (54 with bilateral gynaecomastia and 7 with monolateral disease) were, treated in the Dept. of Plastic Surgery of the Niguarda Ca' Granda Hospital in Milan from 1985 up to 1995. 26 patients were treated with adenomammectomy; Suction assisted lipectomy was used alone in 4 cases and associated with adenomammectomy in 34 cases. The authors suggest that the associated method is the most effective, the aesthetic results being excellent with an important reduction of post-operative complications (mostly referred as haematoma, seroma).
Abstract: Electric injuries produce deep tissue destruction and in a large number of cases involve the forearm, entering from the hand. The authors report their experience, consisting of 13 cases, with satisfying results, particularly in relation to limb salvage. Salvage procedures, avoiding the amputation and including venous grafts and use of flaps, among which the inguinal flap is mostly used, are considered. Late necrosis occurring under grafted tissues often requires further surgery, including tendon and nerve grafts and scar revisions with skin grafts or flaps.
Abstract: Restorative tendon transfer in upper limb palsy should be regarded as an important tool in hand surgery. An adequate planning and patient selection must be required, as well as several techniques can be used. Particularly, associated articular lesions must be detected and cured in the same time. Wrist extension palsies should be treated surgically with PT or LS transfer, whereas flexion palsies can be corrected with opportune balance in movements. Finger palsies can be treated with Zancolli's methods, including MP plasties and "lazos". Thumb palsies can be considered for extensor muscles transposition or reflexionplasties.
Abstract: The role of autogenous vein grafts in nerve regeneration was studied in a rat model. Three groups of animals underwent autogenous vein grafting for ischiatic nerve regeneration, and were sacrificed 30, 60, and 90 days after surgery. Samples obtained were processed for S.E.M. study. Nerve regeneration consisted of two stages: the first (up to 60 days) was characterized by the presence of active endothelial cells; the second (after 60 days) by cell disappearance, with the venous wall acting as a protective conduit throughout both steps. Complete qualitative morphologic and functional studies of neural regeneration are presented, confirming previous investigations.
Abstract: The effects of chronic compression of the cranial bone due to progressive expansion of the scalp have been investigated. Ten patients were studied, 6 adults and 4 children, who were treated for congenital (microtia) or acquired (burns or traumatic) deformities by chronic expansion over a 2-month period. All underwent computed tomography scans of the expansion site prior to introduction of the expansion device, immediately before removal, and at 9 months after the operation. A case of postburn alopecia was lost to the study, because the patient, who had ultimated scalp expansion, did not return for flap advancement. Instead, she came back 3 months later, without the expander, which had been removed at another institution following an automobile accident. In this case, because of slower healing, we performed computed tomography scans 18 months postoperation. During the second procedure (expander removal and flap transposition), bone samples for histological examination were collected directly underneath and along the perimeter of the expanders. Macroscopically, the bone appeared thinned and had a reduced convexity. This reaction, although temporary, appeared more intense in the children and in the posttraumatic cases. Histological examination showed osteoclastic activation, bony hypotrophy, and reaction (deposition of osteoid matrix) under the device, with consequent bone resorption and remodeling. A marked hyperplasia with a hyperostotic reaction was observed around the expanders. At 9 months postoperation, in most cases, a complete normalization was confirmed by computed tomography scans. Expansion of target (fontanellar and sagittal) areas of the skull in children, as well as previous trauma to both scalp and skull should be taken into consideration as a risk factor. Further investigations are suggested.
Abstract: A group of 18 burned patients was excised between days 2 and 5 postburn days, while 20 patients were operated later, between days 25 and 35 postburn. After early excision the wounds covered with meshed grafts contracted to a mean wound size of 56 per cent while the wounds covered with non-meshed grafts contracted to a mean wound size of 64 per cent. After late excision wounds covered with meshed grafts contracted to a mean wound size of 40.5 per cent while wounds covered with non-meshed grafts contracted to a mean wound size of 51.5 per cent. With early excision, meshed grafts grew back to a size of 78.5 per cent while non-meshed grafts grew back to a size of 91 per cent. With late excision, meshed grafts grew back to a size of 69.5 per cent while non-meshed grafts grew back to a size of 75.5 per cent.
Abstract: In this paper the authors present their experience in the surgical treatment of gynecomastia; the different surgical techniques used (liposuction, adenomammectomy, liposuction associated with adenomammectomy) are compared bilaterally 42 patients (37 patients) were affected of bilateral gynecomastia, 5 patients monolateral only (age 18-38 years) were treated in the Department of Plastic and Reconstructive Surgery-Ca' Granda Hospital of Milan, from 1985 to 1991. 12 patients were treated by the adenomammectomy technique; plain liposuction alone was used in 4 patients only. The associated method (liposuction and adenomammectomy) was performed on 26 patients. The results obtained suggest that the associated method is usually the most effective, because esthetic results are excellent and post-operative complications are very low. In selected cases however the other techniques should be preferred, and the criteria of selection are discussed.
Abstract: Two patients presented with multicystic lymphatic malformations of the penis. These were congenital and progressive, and both were successfully treated by excision after injection of methylene blue.
