Perianal Paget's disease-Report of a rare case

INTRODUCTIONPerianal extra-mammary Paget's disease is a rare skin disorder of unknown aetiology, which is frequently associated with malignancy. This case report draws attention to this rare condition and comments upon its diagnosis and treatment.PRESENTATION OF CASEA 64-year-old otherwise fit man, presented to us in 2006 with one-year-long history of perianal irritation. On examination there was an erythematous discoid skin lesion in the right perianal area. The lesion was excised with wide margins and the defect closed with a local transposition flap. Histology confirmed extra-mammary Paget's disease (EMPD) with a focus of invasion showing a well-differentiated mucinous adenocarcinoma. Adjuvant therapy was not advised. On follow-up in 2011, a small irregular skin lesion, well away from the previous excision site was noted on the left perianal area. Biopsies from this lesion confirmed EMPD with no focus of invasion. Once again wide local excision with closure using local transposition flap was undertaken. Long term follow up has been advised.DISCUSSIONThe optimal treatment for Perianal Paget's disease (PPD) remains controversial. Surgery is the commonest modality used with wide local excision being the treatment of choice for resectable disease. We report herein a short review of various therapies reported so far in the management of this rare disorder.CONCLUSIONA thorough initial evaluation and long-term follow-up is essential to identify recurrence and the development of other related malignancies.     

Management of pyoderma gangrenosum with combination of systemic treatment,vacuum-assisted closure and synthetic dermal substitute

Pyoderma gangrenosum (PG) is a destructive, necrotizing cutaneous process where surgical debridement can produce 'pathergy' phenomenon. Actually, an accepted strategy is to control the disease medically and follow-up with delayed surgical intervention with a split-thickness skin grafting after prolonged courses of immunosuppressive therapy. We report two cases of pretibial PG, one of them a complicated case of a 23 year-old woman with ulcerative colitis and a huge PG which was successfully treated with a synergistic approach utilizing a sequential protocol with systemic treatment, surgical debridement, antimicrobial silver dressing (Acticoat®), vacuum-assisted closure (VAC) therapy and a double layer of synthetic dermal substitute (Integra®) with a skin graft. A systematic review of the literature displays no previous cases utilizing this combined approach. Rare case reports have described VAC therapy use in the management of PG, and only one has described Integra® use. In both cases, rebuilding of the scaffolding were achieved, there was no evidence of recurrence of PG, the cosmetic results were overall satisfactory without limitation of movement for extension and flexion of the foot.Level of Evidence: Level V, therapeutic study.     

Surgical treatment of hidradenitis suppurativa

Hidradenitis suppurativa is a skin disease involving the apocrine sweat glands which often becomes chronic. The aetiology is not completely known, but the mainstays of medical treatment are antibiotics, which gives temporary relief but do not essentially alter the course of the disease. We describe our results of treating 138 affected patients by radical excision of the diseased areas between 1978 and 1999. Postoperative follow-up ranges from 3 months to 21 years; we compiled data from the patients' casenotes and circulated a questionnaire, which 116 patients completed. Median age at onset of disease was 23 years and the interval before radical surgery was 10 years. Altogether 367 affected sites were excised; most cases required skin grafting. There were no serious surgical complications. In 38 patients (33%) the disease recurred to some degree, and 14 of them required further operation. Six patients had a subsequent operation to improve the aesthetic result. Ninety-six of the patients (83%) answered that they would recommend the procedure to other patients under similar circumstances. In our opinion excision and skin grafting is a valuable treatment in cases of severe hidradenitis suppurativa.     

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic, debilitating disease of apocrine gland-bearing skin. Its management must be individualized according to the site and extent of the disease. Initial conservative measures with antibiotics, local wound care, and limited incision and drainage can alleviate the acute symptoms, but more radical surgery will likely eventually be necessary in order to control and prevent recurrent disease. Options include unroofing and marsupialization, local excision, or more extensive operative excision with primary or secondary closure, skin grafting, or flap coverage of defects. Wide excision will offer the most definitive therapy, with the trade-off being a higher morbidity. Split-thickness skin grafts in the anal canal may contract and result in anal stenosis and should be avoided. Perianal disease is often best managed with local excision alone, with primary closure for small defects, and either unroofing or healing by secondary intention for larger wounds.     

Skin grafts for circumferential coverage of perianal wounds

A technique for circumferential skin grafting of the perianal skin after excision of Bowen's disease is described. The technique has proved satisfactory. The protocol for perioperative management of the bowel and the regimen of strict bed rest must be followed carefully.     

One-step grafting procedure using artificial dermis and split-thickness skin in burn patients

The study aimed to achieve a one-step grafting procedure using artificial dermis and split-thickness skin. We performed simultaneous grafting of artificial dermis and skin in two severely burned patients. Artificial dermis was treated with fresh autogenous platelet-derived wound-healing factors (PDWHF), cryopreserved allogeneic cultured endothelial cells, and fibroblasts. Dermal microvascular endothelial cells and fibroblasts were obtained from a single human donor’s skin. The cultured cells were cryopreserved until use in grafting. The PDWHF was prepared from autogenous blood from each patient prior to the surgery. In two patients, the artificial dermis treated with this method was grafted to a full-thickness burn wound. Immediately after artificial dermis grafting, meshed split-thickness skin was grafted. In each case, the skin graft took well, and the skin texture was acceptable. Histological examination revealed that bovine collagen tissue remained in the dermis after surgery, indicating the success of the simultaneous grafting of the artificial dermis and the skin. The present study indicates that one-step grafting of artificial dermis and split-skin is possible when the artificial dermis is treated with PDWHF and cultured endothelial cells and fibroblasts. Level of Evidence: Level V, therapeutic study.     

Operative management of chronic hidradenitis suppurativa of the scrotum and perineum.

Hidradenitis suppurativa of the perineum and scrotum is a progressive disease and, if left untreated, may require a radical operation for its control, including orchiectomy and skin grafting. Five patients with this disease who had failed to respond to antibiotics, and incision and drainage were treated with excision of the involved scrotal and perineal tissue. Healing was promtp and contractures were minimal. Early operative management of this chronic disease is encouraged.     

Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns

The consequences of receiving a cutaneous sulfur mustard (SM) burn are prolonged wound healing and secondary infection. This study was undertaken to find a treatment that promotes quick healing with few complications and minimal disfigurement. Multiple deep SM burns (4 cm diameter) were generated on the ventrum of weanling pigs and treated at 48 h. Four treatments were compared: (1) full-thickness CO₂ laser debridement followed by skin grafting; (2) full-thickness sharp surgical tangential excision followed by skin grafting, the “Gold Standard” used in deep thermal burns management; (3) partial-thickness laser ablation with no grafting; and (4) partial-thickness sharp excision with no grafting. A computer controlled, raster scanned, high-powered continuous wave (cw) CO₂ laser was utilized. Ulceration, wound geometry, and wound contraction were evaluated during a 36-day healing period. Histopathological evaluations were conducted at the end of the healing period. Engraftment rates were similar between both methods of debridement. Laser debridement followed by skin grafting was as efficacious in improving the wound healing of deep SM burns as the “Gold Standard.” Full-thickness laser debridement of these small total body surface area (TBSA) burns was time efficient and provided adequate beds for split-thickness skin grafting. Laser debridement offered additional benefits that included hemostatic control during surgery and minimal debridement of normal perilesional skin. Mid-dermal debridement by sharp excision or laser ablation without grafting produced less desirable results but was better than no treatment.     

Anesthetic management of the pregnant burn patient: excision and grafting to emergency Cesarean section

Pregnant patients with burn injuries present a unique challenge for general medical care and require special anesthetic considerations. A 21 year old woman at 28 weeks' gestation, who suffered 45% total burn surface area partial and full-thickness burns during a fire in her home, is presented. Anesthetic management included preparation and care during excision and skin grafting procedures, and during emergency Cesarean delivery. The management plan was developed by a multi-disciplinary team of personnel from the departments of burn surgery, obstetrics, anesthesiology, neonatology, and nursing.     

Intérêt de la greffe de peau dans la prévention des récidives de la maladie de Dupuytren

ObjectiveThe aim of the study was to evaluate the ability of full thickness skin grafts to prevent recurrence of aggressive Dupuytren's contracture.Patients and methodsEighteen patients presenting with bilateral recurrent Dupuytren's contracture were identified and retrospectively reviewed with a mean follow-up of 8.8 years after dermofasciectomy and skin grafting onto at least one hand.ResultsOnly two patients presented with a complete diathesis of Dupuytren's contracture, such as defined by Hueston, thus confirming that recurrence is still not predictable. Each patient sustained 3.6 procedures on average. Thirteen patients were skin grafted on a single hand and five patients bilaterally. Recurrence occurred in three instances after skin grafting and in all instances when skin graft was not performed. Finally, three peroperative and five postoperative complications were reported.ConclusionSkin grafting was able to prevent further recurrence of recurrent Dupuytren's contracture in 20 out of 23 hands with more than 8 years of follow-up. Since recurrence is still difficult to predict, primary skin grafting remains controversial. Indications for the procedure are more definite once recurrence has occurred.     

Is dermatome shaving a potential treatment for actinic keratosis in organ transplant recipients? A cross-sectional study

Background

Non-melanoma skin cancer (NMSC) is correlated with high morbidity and mortality in solid-organ transplant recipients (OTR) and it appears after a mean interval of 8 to 10 years. Prophylactic treatments are still required to prevent the development of NMSC. This study aims to investigate whether dermatome shaving reduced the occurrence of keratotic skin lesions in OTRs.

Methods

A retrospective study was conducted. One thousand and twenty-four patients who had a split-thickness skin graft due to NMSC excision were identified in the Central Denmark Region and the Region of Southern Denmark between 1996 and 2011. Eleven of these patients were OTRs at the time of split-thickness skin grafting and were included in the study. The patients were examined for keratotic skin lesions, representing suspected premalignant lesions, on the donor area of the split-thickness skin graft, recipient area and two corresponding control areas. Epidemiological and medical parameters for each patient were registered via medical records and through patient interviews.

Results

The average time between split-thickness skin grafting and clinical examination was 6.2 years (1.1–16.8). The occurrence of keratotic skin lesions were lower in the donor area compared to both of the control areas (Wilcoxon matched-pairs signed-rank test, p?=?0.024, respectively, p?=?0.019).

Conclusions

Dermatome shaving reduced the occurrence of keratotic skin lesions in OTRs and might prevent the development of field cancerization and NMSC. Level of Evidence: Level III, therapeutic study.     

Efficacy of hydrosurgical excision combined with skin grafting in the treatment of deep partial-thickness and full-thickness burns: A two-year retrospective study

IntroductionDeep partial-thickness and full-thickness burn wounds often undergo tangential excision or escharectomy to expose healthy tissue, combined with skin grafting to promote wound healing. However, conventional tangential excision with the humby knife leads to inevitable damage to the dermis while excising burn tissue due to the lack of precision. Indeed, the preservation of dermal tissue is a key factor in determining wound healing and scar quality. The precision and tissue selectivity of the Versajet Hydrosurgical System has been established for excising burn tissue while preserving dermal tissue. In this study, we retrospectively compared the efficacy of "Hydrosurgical excision combined with skin grafting" and "Conventional tangential excision combined with skin grafting" in treating deep partial-thickness and full-thickness burn wounds to demonstrate that hydrosurgery improved the treatment of deep partial-thickness and full-thickness burns.MethodsA total of 86 patients with deep partial-thickness and/or full-thickness burns with a total burn surface area (TBSA) ≤ 25% from July 2018 to July 2020 were included in this study and were divided into experimental (hydrosurgical excision combined with skin grafting, n = 43) and control (conventional tangential excision combined with skin grafting, n = 43) groups. Parameters were analyzed, including the intraoperative blood loss volume per unit area of grafted skin, surgery duration, wound healing time, skin graft survival, and the treatment costs per unit of burned area. Scar assessment was performed at 1 year with the modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA).ResultNo significant difference was found in male to female ratio, age, weight, TBSA, burn depth, skin grafting area (SKA), skin grafting methods, cases treated with carbon dioxide fractional laser or incidence of inhalation injury, and the incidence of hypovolemic shock between two groups(p > 0.05). Compared with the control group, patients treated with hydrosurgical excision combined with skin grafting experienced less intraoperative blood loss volume per unit area of grafted skin (p < 0.05). The mVSS-TBSA of patients that underwent hydrosurgical excision combined with skin grafting was significantly improved in comparison to the control group (p < 0.01). No significant difference was found in surgery duration, wound healing time, skin graft survival and treatment costs per unit of burned area between the two groups (p > 0.05).ConclusionHydrosurgical excision combined with skin grafting reduced intraoperative blood loss volume per unit area of grafted skin, improved scarring 1-year after injury, and did not increase the treatment costs per unit of burned area. This technique provides a novel alternative for managing deep partial-thickness and full-thickness burn wounds.     

Les plasties dans la prise en charge chirurgicale de la maladie de Verneuil

Surgical treatment of Verneuil’s disease can use to skin grafting techniques or plastic surgery to cover the losses of substance induced by excision of the lesions. The choice of technique depends on the area needed to be covered.     

Combined prosthetic incisional hernioplasty and panniculectomy—a 5-year single-centre experience

Background

Ventral incisional hernia patients develop limitation in physical activities as the hernia enlarges, leading to alteration in their lifestyle, quality of life, aesthetic deformities, and occasionally to complications. Cosmetic improvement of the abdomen, an important objective of hernia repair, can be achieved when hernia repair is combined with panniculectomy. The authors undertook this study to review their experience of the integration of hernia repair and panniculectomy to improve the understanding and treatment of this condition.

Methods

A retrospective analysis of the records of patients who underwent abdominal hernia repair with panniculectomy from 2005 to 2010 was undertaken. The records were reviewed for patient demographics, hernia etiology, risk factors for recurrence, previous surgeries, previous approach, type of repair, incision approach, complications, length of hospital stay, and duration of follow-up. Surgical management included mesh hernia repair and pannus excision.

Results

Of the total 45 patients, mean age was 42.37 years and mean follow-up was 24.4 months. Twelve patients had recurrent hernias. Most of the patients underwent retrorectus underlay mesh repair [39 (86.67 %)], while 6 (13.33 %) underwent onlay mesh technique. Six (13.33 %) patients developed minor skin necrosis, while one (2.22 %) had skin flap necrosis requiring debridement and skin grafting, three (6.67 %) hernias recurred, one (2.22 %) had seroma formation, and one (2.22 %) developed sacral pressure sore.

Conclusion

This technique provides both functional and aesthetic benefits and generally meets the needs of the patients. It is safe, with a low risk of postoperative complications. Level of Evidence: Level IV, therapeutic study.     

Phallic preserving surgery in patients with invasive squamous cell carcinoma of the penis

PURPOSE: Standard surgical methods to eradicate invasive squamous cell carcinoma of the penis often result in significant deformities. Wide local excision with skin grafting in select cases results in the preservation of normal phallic appearance and function. MATERIALS AND METHODS: Seven patients with invasive squamous cell carcinoma of the penis were treated with wide excision and resurfaced by 1 of 3 methods, namely 1) a split-thickness graft, 2) a full-thickness graft or 3) shaft skin advancement. RESULTS: At 1 to 5 years of followup there was 1 local recurrence proximal to the original resection site. Local excision of recurrence resulted in no evidence of disease at 2 years of followup following repeat excision. All other patients had no local recurrence. CONCLUSIONS: In select cases wide local excision with grafting or skin advancement results in a normal phallic appearance without jeopardizing cancer control.     

Negative pressure wound therapy using gauze and foam: histological,immunohistochemical, and ultrasonography morphological analysis of granulation and scar tissues

Background

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.

Methods

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.

Results

Histological, immunohistochemical, and ultrasonographical results after gauze-based NPWT showed a minor tissue thickness and disorganization and less sclerotic components.

Conclusions

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.     

Venogenic impotence following dermal graft repair for Peyronie's disease.

Peyronie's plaque excision with dermal grafting generally offers good cosmetic results for patients who require surgical intervention for Peyronie's disease. However, postoperative impotence has been reported in 12 to 100% of such patients. The mechanism of impotence in this setting is not well defined. We present 3 men who had venogenic impotence after plaque excision and dermal grafting for Peyronie's disease. One patient has subsequently responded well to dorsal vein ligation, 1 has chosen an effective nonoperative method of management and 1 continues to consider the options. We report venous leak as an organic cause of impotence after plaque excision and dermal grafting for Peyronie's disease, and its successful management by dorsal vein ligation. The implications of these findings in the surgical management of Peyronie's disease are discussed.     

PRIMARY LYMPHEDEMA OF THE GENITALIA IN CHILDREN AND ADOLESCENTS

Purpose

Congenital lymphedema is a rare disorder that may result in disfiguring edema of the male genitalia. We reviewed our experience with 5 cases to advance our understanding of this challenging problem.

Materials and Methods

Four boys with significant lymphedema underwent excision of the involved subcutaneous genital tissue and coverage with local skin flaps. Two boys in whom this approach failed later underwent complete excision of the involved subcutaneous tissue and skin, and coverage with split thickness skin grafts. The boy with minimal edema was observed.

Results

Two of the 4 boys who underwent subcutaneous genital tissue resection and coverage with local skin flaps are markedly improved, although 1 requires further revision. In the other 2 boys treatment failed, necessitating repeat genital tissue excision and grafting. While there have been no recurrences in the grafted areas, each patient has required additional operations to manage recurrent edema in adjacent tissues of the perineum and inguinal region, and in 1 significant contraction of the grafted skin developed. Mild genital lymphedema in the remaining patient has remained stable during 10 years of followup.

Conclusions

Congenital lymphedema of the genitalia is a challenging problem. Recurrences requiring multiple operations are common. We recommend expectant management of mild cases. In more severe cases excision without grafting should be attempted. While skin grafting may be the most definitive solution, it does not prevent recurrence in adjacent regions, and it carries the risk of skin contraction. Skin grafts should only be used when other techniques have failed.     

The surgical management of dystrophic epidermolysis bullosa (excluding the hand).

Fifty patients with Dystrophic Epidermolysis Bullosa (DEB) underwent surgery including release of limb, oral, anal, eye and penile contractures and treatment of chronic skin ulceration or skin tumours. Correction of contractures involves extensive release of skin and underlying tissues, with split skin grafting of secondary defects. Specific regions are discussed. Recurrence is inevitable due to ongoing disease; however, functional improvement is obtained for several years. Management of chronic skin ulceration with split skin grafting has failed to produce long term healing, with local flaps successful but limited by the problem of donor site instability. Nine of the 17 patients over 20 years of age developed squamous cell carcinomas (29 lesions), benign hyperkeratosis (9) or malignant melanoma (1) requiring excision and skin grafting or amputation of digits. Local recurrence was infrequent (3 squamous cell carcinomas), with distant metastatic spread occurring in 1 patient.