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Objective: The burden of chronic wounds did not disappear during the Covid-19 pandemic, so new ways to address healthcare practitioner (HCP) education had to evolve. The Teach, Try, and Talk (T3) programme was conceived in 2021 with HCPs in southern Europe (Italy, Spain and Portugal). Method: Virtual education sessions with experienced HCP guest speakers were held and a five-layer hydrocellular polyurethane foam dressing (HPFD) was introduced as a way of reducing dressing change frequencies and improving clinician satisfaction. HCPs recorded their experience of the HPFD using an online form and participated in a further virtual session with experienced HCPs to discuss the results. Results: There were a total of 190 responses. A significant dressing change reduction from 3.6 changes per week to 1.8 with the HPFD (pConclusion: The T3 programme is a highly successful method of training delivery and practice improvement across a variety of healthcare settings in southern Europe, helping support HCP engagement and ongoing development in challenging times during the Covid-19 pandemic. The programme can be adapted considering the needs of different HCPs and payor and/or healthcare systems.

The COVID-19 pandemic deeply impacted the capacity of the health systems to maintain preventive and curative services, especially for the most vulnerable populations. During the pandemic, the wound healing centres in Italy assisted a significant reduction of the frequency of their hospital admission, since only urgencies, such as severe infections or wound haemorrhagic complications, were allowed to the hospital. The aim of this multidisciplinary work is to highlight the importance of a new pathway of wound care with patient-based therapeutic approach, tailored treatments based on the characteristics of the wound and fast tracks focused on the outpatient management, reserving hospital assessment only for patients with complicated or complex wounds. This analysis highlights the point that patients with chronic wounds need to be critically evaluated in order to find the best and most appropriate care pathway, which should vary according to the patient and, especially, to the characteristics of the wound. Moreover, the most adequate topic antiseptic should be started as soon as possible. An appropriate and correct management of the wound care will allow to link the knowledge based on years of clinical practice with the new challenges and the need to visit patients remotely, when possible.

Objectives Chronic wound infections may delay the healing process and are responsible for a significant burden on healthcare systems. Since inappropriate management may commonly occur in the care of these patients, this review aims to provide a practical guide underlining actions to avoid in the management of chronic wound infections. Methods We performed a systematic review of the literature available in PubMed in the last 10 years, identifying studies regarding the management of patients with chronic wound infections. A panel of experts discussed the potential malpractices in this area. A list of ‘Don'ts’, including the main actions to be avoided, was drawn up using the ‘Choosing Wisely’ methodology. Results In this review, we proposed a list of actions to avoid for optimal management of patients with chronic wound infections. Adequate wound bed preparation and wound antisepsis should be combined, as the absence of one of them leads to delayed healing and a higher risk of wound complications. Moreover, avoiding inappropriate use of systemic antibiotics is an important point because of the risk of selection of multidrug-resistant organisms as well as antibiotic-related adverse events. Conclusion A multidisciplinary team of experts in different fields (surgeon, infectious disease expert, microbiologist, pharmacologist, geriatrician) is required for the optimal management of chronic wound infections. Implementation of this approach may be useful to improve the management of patients with chronic wound infections.

Coverage of the heel defects usually represents a challenge for the proper reconstructive requirements of the weight-bearing area of the foot. The presence of multiple limb amputation may represent a further concern for conventional free flap donor sites and the patient’s functional limitation, thus making reconstruction even more challenging. Amputee patients may be subjected to a higher risk of foot ulcerations and choosing the more appropriate reconstructive option in such patients is crucial. Here we describe the application of the medial plantar flap as a first-line option in a 66-year-old amputee patient with a squamous cell carcinoma arising from chronic ulceration on the left heel, that was successfully treated with limited functional limitations and excellent anatomical contour of the foot. Despite its use has been widely described for heel reconstruction, we believe that medial plantar flap would deserve greater relevance in the reconstructive scenario in such challenging cases.

INTRODUCTION Breast reduction is one of the most common procedures performed by plastic surgeons worldwide. Despite that several techniques have been proposed for management of ptotic or hypertrophic breasts, most of them often deal with too large breast bases, poor breast projection, persistent "dog ears," and a certain percentage of bottoming out. Lower-pole shaping of the breast remains one of the challenge of vertical mammoplasty. MATERIALS AND METHODS The authors report their 5-year-long experience with a modification of the vertical scar technique, the "arrow flap," in which they harvest a double lateral glandular and cutaneous flap, to tighten and better shape the base of the breast and to improve the breast projection with a "double-bra" effect. From April 2015 to February 2019, 75 patients with moderate to severe macromastia/breast ptosis underwent bilateral reduction mammoplasty. RESULTS Postoperative outcomes showed an overall satisfactory results and low incidence of complications. Two patients presented with an asymmetry between the 2 breasts, and no nipple-areola complex necrosis occurred. One patient reported a wider vertical scar, whereas no bottoming out was observed. CONCLUSIONS All patients reported a stable and durable projection of the breast, with pleasant cosmetic results. By combining short scars and narrow base, we can obtain a pleasant lower pole reshaping of the breast, even in that challenging cases of large and squared breast. The authors believe that this technique provides a useful surgical option, increasing the versatility of the superior pedicle vertical mammaplasty both for mastopexy and breast reduction, even in cases of severe macromastia.

Sarcomatoid melanoma is an extremely rare pattern of malignant melanoma, and only few cases have been described throughout the literature. We herein report a case of a patient with newly diagnosed, metastatic giant sarcomatoid melanoma of the arm. The patient underwent surgical removal of the huge mass, and NGS sequencing demonstrated BRAF V600E mutation. In view of histological, immunohistochemical and molecular findings, a combined BRAF/MEK inhibitor (BRAF/MEK-i) therapy was prescribed as first line treatment. A complete response (over one year) to targeted therapy was obtained, and no adverse events have been reported. The patient maintained a full range of shoulder and elbow movements, and she is able to live independently and resume her daily activities. We therefore recommend that all patients with undifferentiated melanomas, sarcomatoid cutaneous malignancies or other mesenchymal tumours, should undergo BRAFV600E mutation testing.

Highlights • Final thickness of the neodermis after ADM application is unpredictable. • ADM should be restricted to large lesions involving more than one half of the nose. • For smaller rhinophyma, or lesions of the nasal tip, flap surgery is suggested. • Excision should be performed as wide as possible on the healthy tissue. • Lipofilling after ADM reconstruction should be often considered., Introduction nasal reconstruction after rhinophyma surgery could be challenging. In the last decade, some authors proposed the use of dermal substitutes, but only few case reports have been described throughout the Literature. Presentation of case we described a new case of severe and disfiguring rhinophyma treated by total excision and a two-step reconstruction by using acellular dermal matrix and subsequent full-thickness skin graft. Despite an overall improvement of the nasal shape and a good functional recovery were observed after 12 months of follow-up, the aesthetic outcome was not satisfactory and the patient required further surgical revisions. Discussion the use of ADMs in rhinophyma poses some important aspects to be discussed. The resorption rate of the matrix and retraction rate of the skin graft make the final thickness of the neodermis unpredictable. Moreover the location of phymatous lesions and the extent of the surgical removal may strongly impact the final aesthetic outcome, often leading to a multistep procedure and patient dissatisfaction. Conclusion although we believe that ADM represents a simple and reliable alternative for surgical reconstruction after rhinophyma, basing on our clinical experience we suggested some important tips and tricks in order to avoid surgical revisions, and both surgeons and patients should be aware about the potential drawbacks of this technique.

Il progetto consiste nella creazione di un opuscolo informativo, all’interno del quale sono spiegate le principali informazioni relative la gestione del paziente portatore di Lesioni da Pressione. Le nozioni espresse sono alla base del percorso terapeutico, in quando sono indirizzate a lettori non esperti nel campo delle medicazioni difficili. Viste le esigenze del pubblico di assistere a questa tipologia di pazienti, in molti casi in maniera autonoma per quanto riguarda la medicazione vera e proprio, si è ritenuto necessario fornire del materiale per aumentare le conoscenze dei caregiver informali. Lo scopo ultimo è proprio quello di fornire un metodo semplice e sicuro di apprendimento per i cittadini che si occupano della gestione del paziente e delle relative medicazioni; considerando sempre un affiancamento da parte di professionisti. Gli obiettivi che ci si pone con il progetto sono: valutare e visualizzare quelli che sono gli aspetti importanti per i soggetti aventi Lesioni da Pressione, questo comprende la definizione, prevenzione, classificazione e trattamento; l’importanza della continuità assistenziale per questa tipologia di paziente; informare il cittadino su cosa sono le lesioni da pressione (quali sono le accortezze quotidiane da dover attuare per evitare il peggioramento o lo stallo della condizione) ed infine il trattamento vero e proprio tramite l’insegnamento delle medicazioni difficili e della loro applicazione in base ai diversi casi (essendo un argomento vasto e materia di specializzazione in ambito infermieristico si tratterà in maniera semplificata in modo da dare informazioni basilari ma utili). Per la creazione dell’opuscolo è stata effettuata una revisione della letteratura che vede la consultazione di due linee guida, undici articoli e due testi.

La guarigione delle ferite è un processo complesso che coinvolge molte interazioni sinergiche tra diverse linee cellulari, citochine, enzimi e fattori di crescita. Negli ultimi anni sono stati introdotti diversi biomateriali e medicazioni bioattive che si ritiene svolgano un ruolo attivo nella guarigione delle ferite. Sia il collagene che l’Acido Ialuronico (AI) sono stati ampiamente adottati per la gestione delle ferite e la sua combinazione, utilizzata come medicazione bioattiva, è stata studiata. Abbiamo riportato la nostra esperienza clinica con una medicazione avanzata composta da AI più collagene eterologo di tipo I applicato su ferite acute e croniche di diversa eziologia in una coorte retrospettiva di 30 pazienti. Tutti i pazienti inclusi avevano ferite cutanee portate a guarigione completa per seconda intenzione, e tutte le ferite sono state trattate utilizzando Bionect Pad® (BP). Se necessario, alcuni casi sono stati gestiti con trattamenti combinati al fine di ottenere un’adeguata preparazione del letto della ferita prima dell’applicazione di BP. Trenta pazienti con età media di 60,2 anni sono stati trattati per ferite di diversa eziologia. La tipologia di ferite trattate includeva ulcere venose, ferite post-traumatiche, complicanze di ferite chirurgiche, lesioni da decubito, ustioni, ulcerazioni peristomali e ulcerazioni cutanee dopo radioterapia. Il tempo medio di guarigione è stato di 31 giorni (range: 21-76 giorni). Sulla base dei nostri risultati incoraggianti, riteniamo che tali medicazioni bioattive possano essere considerate un’alternativa utile e affidabile ad altri metodi di trattamento ben noti e consolidati, come le matrici dermiche acellulari o altre medicazioni avanzate, in casi selezionati.

Presso la Struttura Organizzativa Dipartimentale (S.O.D.) Clinica di Chirurgia Plastica e Ricostruttiva di Ancona sono stati trattati con miele medicale consecutivamente, nell’arco di 24 mesi, 75 pazienti affetti da lesioni cutanee croniche. Nell’articolo vengono descritti gli ottimi risultati ottenuti in termini di riduzione dei tempi di guarigione delle lesioni trattate, e vengono descritte le caratteristiche chimiche e fisiche del miele medicale che ne spiegano in forma scientifica l’azione.

Background The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dual-plane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates. Materials and Methods A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retro-pectoral muscular position + ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded. Results We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were pre-pectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma. Conclusion Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Paraffinoma is a destructive complication of paraffin oil injection, usually associated with massive tissue destruction, thus requiring radical surgery and subsequent complex reconstruction. Although breast and penile paraffinomas have been widely described and their management is quite standardized, paraffinomas of the knee are still rare and only few case reports or small case series are available in the current literature. We describe the case of a 77-year-old man with a large paraffinoma of the right knee that occurred after self-injection of paraffin oil, 58 years before. He underwent wide surgical resection of the soft tissues overlying the knee and subsequent two-stage reconstruction by using acellular dermal matrix and, after 20 days, split-thickness skin grafts. Follow-up after 16 months showed no signs of skin ulcerations or inflammation, with an overall improvement in function. Even though conventional flap reconstructions may be still useful, the authors believe that acellular dermal matrices represent a safe, reliable, and less invasive alternative for challenging soft tissue reconstructions even in elderly patients with multiple medical problems.

Background Heel reconstruction represents a challenge for all plastic surgeons due to the anatomical and functional features of this weight-bearing area. In the last decade a combined use of acellular dermal matrices and skin grafts has been proposed as a reliable and less invasive alternative for complex wound management; nevertheless only a few cases have been reported in the literature. Methods We describe the long-term outcome of 2 cases of severe degloving trauma of the plantar region with massive soft tissue defects of the foot, that underwent surgical reconstruction with artificial dermis and skin grafts. At the fifth year of follow-up, both patients underwent a clinical and a computerized gait analysis to study their functional outcomes and the kinematics of their gait. Results Both patients recovered functional ambulation and returned to their own work and vocational activities, showing a symmetric gait and parameters of upright posture fully comparable to normality. Conclusions Despite the initial concerns about the use of acellular dermal matrices and skin grafts for this kind of injury, they seem to be a simple and safe alternative for weight-bearing reconstruction of the degloved foot. The authors believe that the current study yields useful information and reassurance about their long-term reliability.

Gorlin-Goltz syndrome is mainly characterised by the development of numerous multicentric and relapsing cutaneous basal cell carcinomas (BCCs). A major problem for patients with Gorlin-Goltz syndrome is the large amount of BCCs that can invade the deep underlying structures, especially the face. Here, we describe the case of a 23-year-old male affected by Gorlin-Goltz syndrome. He had recurrent BCCs on a hairless scalp and dorsum since he was 17 years old and underwent four surgical procedures to excise BCCs, including a reconstruction with anteromedial thigh perforator flap. For each of the surgical procedures, a phenotypic study on peripheral blood mononuclear cells using flow cytometry was performed on the same day of surgery, and on days 7, 14 and 21 after surgery. The role of the tumour-specific cytolytic immune response as a potential future treatment of syndromic BCCs and its trend in relation to surgical ablation of large portions of tumour tissue was examined, and the cosmetic and therapeutic results are shown.

Prontosan® Debridement Pad (PDP; B. Braun) è un nuovo presidio disegnato per migliorare il processo di debridement meccanico. In questo lavoro riportiamo i risultati di un complesso progetto condotto al fine di sviluppare consenso tra gli esperti sul migliore modo di impiegare questa nuova tecnologia nella pratica clinica. Il progetto si è articolato in tre fasi. Nella prima è stata condotta una estesa revisione della letteratura che ha condotto ad identificare, analizzare criticamente e a riassumere in formato strutturato 27 studi clinici pertinenti. Nella seconda fase le evidenze disponibili sono state discusse in modo sistematico con un pannello di 10 esperti, i quali hanno formulato 12 raccomandazioni per l'impiego clinico del PDP. Queste raccomandazioni sono state quindi sottoposte a votazione formale attraverso il metodo GRADE. Infine, nei mesi successivi, 13 casi clinici provenienti dalla pratica clinica routinaria e trattati in accordo con le raccomandazioni stabilite sono stati raccolti e vengono qui presentati. Nel complesso, i dati disponibili in letteratura e quelli raccolti dalla pratica clinica confermano l'efficacia del PDP come strumento per il debridement meccanico, offrendo vantaggi significativi per una ottimale Wound Bed Preparation e per il controllo del dolore. Il nostro progetto può inoltre essere utile per ottimizzare l'impiego pratico di questo nuovo promettente dispositivo. Prontosan® Debridement Pad (PDP; B. Braun) is a new device designed for mechanical debridement. This paper summarizes the results of a complex initiative aimed to develop consensus among a panel of wound care experts about the optimal use of this new technology. An extensive review of the literature found 27 pertinent papers, which underwent a formal process of critical appraisal and evidence extraction by two independent methodologists. Results are displayed in an evidence report. 12 practical recommendations, concerning management of acute and chronic wounds, have been developed and approved. Main point of strength of this project is the use of a systematic approach to literature review, evidence synthesis and presentation, development and measurement of expert consensus. Moreover, expert panel provided further clinical data, through the reporting of 13 clinical cases managed according to abovementioned recommendations, with a particular focus on burns and chronic ulcers treatment, both in adult and pediatric patients. Overall, results from literature review and from clinical experience confirm that the combined system Prontosan® Solution and PDP is a promising tool useful in the critical phase of debridement in acute and chronic wounds treatment. Efficacy in debris removal and pain reduction are the main points of strength. Our project may contribute to optimize clinical use of this innovative device.

Highlights • Giant basal cell carcinomas are rare and potentially aggressive tumors. • Aggressive surgical resection with suggested wide free margins is suggested. • Soft tissue reconstruction for back lesions may be challenging. • The O-Z flap represents a safe and reliable alternative for back reconstruction., Introduction Giant basal cell carcinomas are rare and potentially aggressive skin malignancies that are infrequently reported in the Literature, and they usually require aggressive surgical resection and immediate soft tissue reconstruction with skin grafts or flaps. The large size of GBCCs has relevant implications not only for the metastatic potential, but even for the reconstructive challenging due to the possible limited availability of tissues for flap coverage. Presentation of case We report the peculiar case of an old patient who underwent to GBCC resection of the back measuring 16 × 13 cm, and immediate reconstruction with a large O to Z flap harvested from the back; one-year follow-up examination revealed a satisfactory result and no recurrence of the disease was observed. Discussion The review of the Literature showed that reconstructive options are mainly determined by the site and extent of the defect, exposed structures and patient characteristics and comorbidities, and previous series reported the use of skin grafts only, pedicled myocutaneous or perforator flaps, exclusively free flaps and a combination of techniques. Therefore, in this scenario local flaps such as O-Z flaps are less invasive procedures, that usually have lower rate of postoperative complications and shorter hospitalization compared to more complex procedures. Conclusions Despite the use of O-Z flap is quite unusual for back reconstruction, we believe that this flap represents a valid and safe alternative in selected cases, particularly in the elderly and medically compromised patients with multiple comorbidities.

Aims Probiotics have the ability to enhance the immune system, produce anti-inflammatory action and promote wound healing process. The first aim of the study was to isolate pathogenic micro-organisms from sites of chronic ulcerative lesion. The second aim was to evaluate probiotic efficacy of SYNBIO® (1:1 combination of Lactobacillus rhamnosus IMC 501® and Lactobacillus paracasei IMC 502® ) in counteracting wound infections. Methods and results Several bacterial pathogens were isolated from chronic ulcerative lesions and identified by morphological, biochemical and molecular techniques. SYNBIO® probiotic formulation was investigated for its antimicrobial activity, minimum inhibitory concentration, co-aggregation and adherence capacity against the isolated pathogens. Moreover, SYNBIO was also tested in combination with some medical devices, using an in vitro model, in order to simulate a real ulcerative wound infection. Probiotic formulation demonstrated an inhibitory action against all the tested pathogens and their mixture (MIX), with an increased ability of co-aggregation during time. In addition, the adhesion percentage of probiotic micro-organisms to human keratinocyte (HaCaT cells) and human fibroblasts (NHF), calculated by an in vitro model, was 19% and 17% respectively, highlighting the possibility to create a protective environment preventing pathogens' biofilm formation in order to contrast infections. Conclusions SYNBIO® probiotics showed a very good antimicrobial capacity and adhesion percentage to HaCaT cells and fibroblasts, giving the opportunity to be successfully used as complement to conventional therapies in the treatment of chronic ulcerative lesions. Significance and impact of the study A new therapeutic approach with probiotics (supplemented in topical applications, excluding side effects) able to eliminate pathogenic micro-organisms and improve healing of chronic ulcerative lesions.

Lo scopo di questo articolo è valutare i risultati ottenibili trattando lesioni difficili attraverso la combinazione di ossigenoterapia iperbarica (OTI) e terapia a pressione negativa (TPN). Individuare le modalità con cui queste possano agire in sinergia coadiuvandosi, al fine di ottimizzare la rigenerazione dei tessuti e favorire la guarigione come qualità e tempi più brevi. Sono stati presi in analisi i dati di tre pazienti trattati presso il Centro Iperbarico di Ravenna che presentavano ferite agli arti inferiori aperte da più di sei settimane. È stato eseguito l’assessment iniziale della ferita e applicato un approccio multi terapeutico OTI e TPN per un periodo compreso tra 3-6 settimane. I pazienti presi in analisi sono giunti a guarigione completa entro 10 settimane di trattamento rispetto alla media di presa in carico per 28 settimane degli altri pazienti trattati presso la stessa struttura (dato reale) e alla media di 12 settimane previste nelle linee guida (benchmark). Le due terapie associate hanno prodotto un esito positivo che avrebbe richiesto tempi e costi maggiori se fossero state utilizzate singolarmente. The purpose of this work is the evaluation of the results obtaineble by treating hard to heal wounds with the combination of Hyperbaric Oxygen Therapy (HBOT) and Negative Wound Pressure Therapy (NWPT). Identify how HBOT and NWPT can act in synergy, in order to optimize tissue regeneration and promote a good quality healing and in shorter time. The study analyzes data of three patients affected, for more than six week, by lower limb wounds and treated at the Hyperbaric Center of Ravenna. The initial wound assessment was performed and a multi-therapeutic approach, HBOT and NWPT, was applied over a period of 3-6 weeks. The patients underwent to a complete healing after a maximum of 10 weeks of treatment compared to the 28-weeks average of other patients treated at the same facility (real data) and the 12-weeks average expected in the guidelines (benchmark).The combination of the two therapies, has led to a positive result saving time and money; the individual use of them would have required more time and costs.

Not available.

The occurrence of pressure ulcers has an important influence on the patient’s quality of life [1].

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Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Fournier’s gangrene (FG) is a disease involving necrosis of perineum and external genitalia; in 95% of cases it is possible to diagnose the Fournier’s gangrene just by physical examination. The clinical presentation of FG varies from an initial localized infection to large areas with necrotizing infection. The disease typically affect elderly men (6°-7° decade) with important systemic comorbidities; women are less frequently affected. Despite improvements in diagnosis and management, the mortality rate nowadays is between 20% and 43%. The severity and mortality of the disease is dependent upon the general condition of the patient at presentation and upon the rate of spread of the infection. Treatment involves a multidisciplinary approach: intensive systematic management, broad-spectrum antibiotic therapy, early surgical debridement (wide abscission of necrotic tissues and surgical drainage of peritoneum, scrotum, penis, and inguinal areas), hyperbaric oxygen therapy; surgery can eventually be repeated if necessary; reconstructive surgery has an important role in the final treatment of the disease. The technical difficulties frequently encountered and the inability to make a complete removal of the necrotizing tissues at the time of surgery in some cases has led to the application of combined techniques, in view of the enhancement effect of specific advanced medications, targeted antibiotic therapy and hyperbaric medicine. We have considered 6 patients affected by Fournier’s gangrene treated at our institution; all the patients received treatment with the help of plastic surgeons of the same institution. After debridement, all the patients were treated with advanced specific dressings consisting of plates and strips made of calcium alginate, hydrogels and polyurethane and twodimensional cavity foams. Reconstructive surgery was necessary in one case. Hyperbaric oxygen therapy (HBO) has been performed in all cases. The multidisciplinary approach, the combined use of HBO therapy and the adoption of advanced specific dressings, have made possible the complete healing of the lesions in a shorter period, avoiding further surgery in 5 out of 6 patients.

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

Negative pressure wound therapy (NPWT) is becoming routine for the preparation of wounds prior to grafting for wound closure. With this purpose, we have been using both foam and gauze-based NPWT obtaining similar proportions of closed wounds and observing less pliable scar tissue on the foam-treated patients. The aim of this study was to compare this two different fillers and to identify if there are different indications for their use according to anatomical areas in relation to the type of granulation and scar tissue obtained. Both foam and gauze patients were compared in terms of depth and wound location, patients' age, and comorbidities. All foam patients were treated at 125 mmHg for an average of 25 days before skin grafting, while gauze patients were treated at 80 mmHg for an average of 21 days before skin grafting. Biopsies of granulation and scar tissues were taken and stained with hematoxylin-eosin and Masson's trichrome stainings, investigating vascular endothelial growth factor (VEGF) and metalloproteinase (MMP). An ultrasound analysis of the closed wounds was also conducted. Histological, immunohistochemical, and ultrasonographical results after gauze-based NPWT showed a minor tissue thickness and disorganization and less sclerotic components. These results support the hypothesis that different fillers generate different scar tissues. The choice of the filler to apply negative pressure should be dictated by the anatomical areas affected by the lesion. Level of Evidence: Level IV, therapeutic study.

Background Breast implants are widely used and at times might cause inflammation as a foreign body, followed by fibrous capsule formation around the implant. In cancer, the inflamed stroma is essential for preservation of the tumor. Mesenchymal stem cells can be recruited to sites of inflammation, and their role in cancer development is debated. The authors assessed the effects of inflammation caused by breast implants' effects on tumor. Methods Mesenchymal stem cells were isolated from the fibrous capsules of women who underwent a second operation after 1 year (presenting inflammation) or after 20 years (not presenting inflammation) since initial surgery. After characterization, cells were co-cultured with MCF7, a breast cancer cell line. The expression of genes involved in oncogenesis, proliferation, and epithelial-to-mesenchymal transition was investigated, followed by Western blot analyses. Results After co-culture with mesenchymal stem cells from the inflamed capsule, MCF7 induced a dose- and time-dependent increase in proliferation. Polymerase chain reaction analyses revealed a dysregulation of genes involved in oncogenesis, proliferation, and epithelial-to-mesenchymal transition. The subsequent evaluation by Western blot did not confirm these results, showing only a modest decrease in the expression of E-cadherin after co-culture with mesenchymal stem cells (both derived from inflamed or control capsules). Conclusion These data indicate that inflammation caused by breast implants partially affects proliferation of MCF7 but does not influence key mechanisms of tumor development.

Introduction Actinic keratosis (AK) is a cutaneous intraepithelial neoplasm appearing within areas referred as ‘fields of cancerization’. AK can progress to invasive squamous cell carcinoma. Treatments that target both clinically visible and subclinical AKs in cancerization fields are able to reduce the risk of malignant progression. Ingenol mebutate gel is a new effective topical therapy for AK, used once daily for 2 or 3 days depending on the location of lesions. Case description Three elderly patients with multiple non-hypertrophic AKs within a contiguous 25-cm2 treatment area on the face or scalp were treated with ingenol mebutate 0.015 % gel once daily for three consecutive days and followed up over a period of 57 days. Discussion and Evaluation Although individual local responses to treatment varied, all patients had total clearance of AK lesions without any sign of recurrence. In addition, all patients said that they were satisfied with the effectiveness of ingenol mebutate treatment and the aesthetic outcome, and would be prepared to use this agent again to treat AK in the future, if necessary. Conclusions These three cases demonstrate that ingenol mebutate 0.015 % gel is effective and well tolerated in a clinical setting, with effective clearance of AK lesions present on the face and scalp, and good patient acceptability.

Wound healing is a systemic response to injury that impacts the entire body and not just the site of tissue damage; it represents one of the most complex biological processes. Our knowledge of wound healing continues to evolve and it is now clear that the wound microenvironment plays a crucial role. The interactions between cells and the surface microenvironment, referred to as the "biofilm," contributes to skin homeostasis and healing. Understanding the functional complexity of the wound microenvironment informs how various factors such as age, ischemia, or bacterial infections can impair or arrest the normal healing processes, and it also allows for the possibility of acting therapeutically on healing defects with microenvironment manipulation. Microbes represent a particularly important factor for influencing the wound microenvironment and therefore wound healing. Moreover, the role of infections, particularly those that are sustained by biofilm-forming bacteria, is mutually related to other microenvironment aspects, such as humidity, pH, metalloproteinases, and reactive oxygen species, on which the modern research of new therapeutic strategies is focused. Today, chronic wounds are a rapidly growing health care burden and it is progressively understood that many non-healing wounds might benefit from therapies that target microorganisms and their biofilm communities. There is no doubt that host factors like perfusion impairments, venous insufficiency, pressure issues, malnutrition, and comorbidities strongly impact the healing processes and therefore must be targeted in the therapeutic management, but this approach might be not enough. In this article, we detail how bacterial biofilms and related factors impair wound healing, the reasons they must be considered a treatment target that is as important as the host's local and systemic pathologic conditions, and the latest therapeutic strategies derived from the comprehension of the wound microenvironment.

Background/Objective: This study aims at the evaluation of the efficacy and safety of a combination therapy based on pidobenzone 4% and fractional CO2 laser or cryotherapy in the treatment of solar lentigines and the prevention of eventual posttreatment hyperchromia. Methods: Efficacy was clinically evaluated by grading the pigmentation level with the Skin Tone Color Scale (STCS), and by grading patients' impression through a Visual Analog Scale (VAS). Results: Our study shows that the associated treatment was safe and that it improves the therapeutic results on solar lentigines and prevents postiatrogenic hyperpigmentation compared with physical therapy alone. Conclusion: The combination of cryotherapy and pidobenzone 4% has been found to be the most useful treatment.

Capsular contracture is one of the most frequent complications following breast augmentation where the capsule begins to squeeze or contract upon itself. The incidence of this phenomenon varies between 0.5 and 30 %, according to the experience of the plastic surgeon. The authors discuss the use of periprosthetic fat transfer in capsule contracture following breast reconstruction. Lipofilling fits well with the breast tissue over time and it adapts to the patient in a very natural way following weight and structural changes. There is still a lack of standardization in the techniques used, but trends towards time management and simplification of technique are appearing. Two cases are described.

We investigated the efficacy of the peptide s-thanatin alone and in combination with tigecycline in an animal model of sepsis induced by cecal ligation and puncture. Adult male Wistar rats were randomized to receive intravenously isotonic sodium chloride solution, 5 mg/kg s-thanatin, 2 mg/kg tigecycline, 5 mg/kg s-thanatin combined with 2 mg/kg tigecycline. The experiment was also performed with administration of the drugs 360 min after the surgical procedure to better investigate the clinical situation where there is an interval between the onset of sepsis and the initiation of therapy. Lethality, bacterial growth in blood, peritoneum, spleen and liver, and NO indices were evaluated. All compounds reduced the lethality when compared to control. In all experiments, the compounds reduced significantly bacterial growth and lethality compared with saline treatment. Treatment with s-thanatin resulted in significant decrease in plasma NO levels compared to tigecycline and control group. The combination between s-thanatin and tigecycline proved to be the most effective treatment in reducing all variables measured. S-thanatin may have potential therapeutic usefulness alone and when associated to tigecycline in polymicrobial peritonitis.