Int. J. Med. Sci. 2011, 8 http://www.medsci.org 377 IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2011; 8(5):377-379 Case Report Surgical Treatment of Depressed Scar: A Simple Technique Francesco Inchingolo1,4 , Marco Tatullo2,4, Fabio M. Abenavoli3, Massimo Marrelli4, Alessio D. Inchingolo5, Roberto Corelli 6, Angelo M. Inchingolo7, Gianna Dipalma4 1. Department of Dental Sciences and Surgery, General Hospital, Bari, Italy 2. Department of Medical Biochemistry, Medical Biology and Physics, General Hospital, Bari, Italy 3. Department of “Head and Neck Diseases”, Hospital “Fatebenefratelli”, Rome, Italy 4. Department of Maxillofacial Surgery, Calabrodental, Crotone, Italy 5. Department of Dental Sciences and Surgery, General Hospital, Bari, Italy 6. Department of Maxillofacial Surgery, General Hospital, Bari, Italy 7. Department of Surgical, Reconstructive and Diagnostic Sciences, General Hospital, Milano, Italy Corresponding author: Prof. Francesco INCHINGOLO, Piazza Giulio Cesare – Policlinico 70124 – Bari. E-mail: f.inchingolo@tin.it – f.inchingolo@doc.uniba.it. Tel.: 00390805593343 – Infoline: 00393312111104 – Fax: 00390883347794 © Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/ licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited. Received: 2011.03.29; Accepted: 2011.06.10; Published: 2011.06.18 Abstract Scar formation is a process consequent to the healing of soft tissues after a trauma. However, abnormal or disturbed collagen production can cause anomalies of the cuta-neous surface and textural irregularities. In the presence of a depressed scar in deep tis-sue, we began to use a new simple technique. In the presence of adherent scars, a small incision is performed so that an undermining scissor can enter inside. The entire cicatri-cial area is undermined on a subcutaneous plane which, by separating the deep scar from the superficial one, completely frees it from the present adhesions so that the existing depression is totally eliminated. In order to avoid the recreation of relapses, stitches formed in a U-shape are made in Nylon or Monocril 2-3/0 are made with a large needle and are placed close together so that a wide aversion is achieved at the margins of the scar and a deep wound closure is obtained by adhering to the undermined tissue. These stitches will then be removed about 2 weeks later. Key words: Depressed scar, plastic surgery, subcision technique INTRODUCTION Scar formation is a process consequent to the healing of soft tissues after a trauma. However, ab-normal or disturbed collagen production can cause anomalies of the cutaneous surface and textural ir-regularities. A cosmetically acceptable scar is often at the level with the surrounding skin, a good color match, soft, and narrow. Favorable lines of closure are usually within or parallel to relaxed skin tension lines: lines due to dynamic action of the underlying mus-culature.1 The scar abnormality will guide the choice of treatment technique. The surgical strategy selected should be based on a correct evaluation of the scar's characteristics. In addition, while any scar with a suboptimal appearance can be revised, greatest pa-tient satisfaction is achieved with realistic expecta-tions.2 CASE REPORT In the presence of a Surgical Treatment of Aortic Arch Hypoplasia • In the early 1990s, 25% of patients could face mortality related to complica-tions of hypertensive disease • Early operations and better surgical techniques should naturally decrease the incidence of residual or recurrent hypertension after coarctation repair • Poorly defined: • Chỉ số Z nhỏ -2 >>> thiểu sản ( can thiệp sớm ) • • • • • • • • • Surgical era 1984–1989: 80 (26) 1990–1999: 151 (50) 2000–2004: 74 (24) Arch repair technique Sternotomy 74 (24) End-to-side anastomosis 58 (78) Extended end-to-end anastomosis (10) Patch repair (8) Subclavian flap repair (1) Miscellaneous arch repair (3) Thoracotomy 231 (76) Subclavian flap repair 96 (42) • Extended end-to-end anastomosis 85 (37) • • End-to-side anastomosis 19 (8) • End-to-end anastomosis • 17 (7) • Patch repair (4) • Miscellaneous arch • repair (3) Associated cardiac • procedures Sternotomy 70/74 (95) • • Ventricular septal defect closure 49 (66) • • Atrial septal defect closure 25 (34) • Arterial switch operation 17 (23) • Pulmonary artery banding 11 (15) Left ventricular outflow obstruction repair 10 (14) Other 14 (19) Thoracotomy 31/231 (13) Pulmonary artery banding 29 (13) Other (1) Intraoperative data Median clamp time (min) 21 (7–272) Median time on bypass (min) 134 (34–340 Neonatal aortic arch surgery results: literature summary Gargiulo G et al MMCTS 2007;2007:mmcts.2006.002345 One stage repair owes • Tissue to tissue technique • Selective cerebral perfusion Ann Thorac Surg 1977;23:261-263 Ann Thorac Surg 1996 May;61(5):1546-8 • Deep hypothermic circulatory arrest: seizures, choreoathetosis and the high impact on the neuro-developmental outcome • Antegrade selective cerebral perfusion: • Perfusion rate: 50 ml kg-1 min-1 • (a) there were no differences regarding the neurological complications, but a significant favorable impact of the bihemispheric ACP on hospital mortality did appear • (b) in 8% of their patients, Willis’s circle was incomplete or absent, and in those patients, left-hemispheric perfusion was put at risk • Dossche KM, Schepens MA, Morshuis WJ, Muysoms FE, Langemeijer JJ, Vermeulen FE Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta Ann Thorac Surg 1999 Jun;67(6):1904-10; discussion 1919-21 • The transcranial Doppler oximeter (NIRS, Somanetics, or INVOS) is a re-liable tool for an estimation of left hemispheric perfusion Apostolakis E, Akinosoglou K The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion foraortic ar ch surgery Ann Thorac Cardiovasc Surg 2008 Jun;14(3):138-48 Pigula FA, Siewers RD, Nemoto EM Regional perfusion of the brain during neonatal aortic arch reconstruction J Thorac Cardiovasc Surg 1999; 117: 1023–1024 Potential Cx of Surgery : Change in arch geometry • Early : airway problem • Late : stiff aorta End to Side anastomosis Bronchial compression by posteriorly displaced ascending aorta in patients with congenital heart disease Retrospectively review CT findings of pts with posteriorly displacement of the ascending aorta • Truncus arteriosus, TOF, PDA, PA with VSD, CoA Focused on Aortopulmonary space Kim et al (Ann Thorac Surg 2002;73:881-6) Three-dimensional computed tomography in children with compression of the central airways complicating congenital heart disease 49 children • TOF(18),cc-TGA(6), d-TGA(2), DORV(5),VSD(5), PDA(2),CoA(3),others (8) • Stenosis site : Trachea (21), bronchus (28) Surgical intervention in 25 • Aortopexy(5), pulmonary arteriopexy(2), pulmonary arterial aneurysmorrhaphy(5),transposition of pulmonary artery(2), division of anomalous vessel(5), thymectomy(3), Lecompte maneuver(1), lobectomy(2) CT is useful in evaluation of obstruction of airway in children Kim et al (Cardiol Young 2002;12:44-50) • The transcranial Doppler oximeter (NIRS, Somanetics, or INVOS) is a re-liable tool for an estimation of left hemispheric perfusion Apostolakis E, Akinosoglou K The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion foraortic ar ch surgery Ann Thorac Cardiovasc Surg 2008 Jun;14(3):138-48 Pigula FA, Siewers RD, Nemoto EM Regional perfusion of the brain during neonatal aortic arch reconstruction J Thorac Cardiovasc Surg 1999; 117: 1023–1024 Summary • • • • End to side technique Airway problem Antegrade selective cerebral perfusion Monitoring of ACP [...]... [4, 5] Evaluation of tumor resectability includes assessment of vascular structures for tumor invasion and vascular anomalies The evolution of imaging over the S Cirillo ( ) Radiology Unit, Mauriziano “Umberto I” Hospital, Turin, Italy Surgical Treatment of Colorectal Liver Metastases Lorenzo Capussotti (Ed.) © Springer-Verlag Italia 2011 7 8 2 Surgical Treatment of Colorectal Liver Metastases past several... 1 Surgical Treatment of Colorectal Liver Metastases of Western Europe Nonetheless, colorectal cancer still represents the second leading cause of cancer-related deaths In fact, even though 85% of patients with a largebowel primary have tumors amenable to curative resection at the time of diagnosis, the disease recurs in more than half of the patients, with the liver involved in up to two-thirds of. .. regardless of the arterial phase pattern (Fig 2.2) [6] During the portal-venous phase, liver metastases typically enhance less than the liver, whereas benign lesions are more enhanced Fig 2.1 A liver metastasis hypoechoic with surrounding liver parenchyma a b Fig.2.2 Liver with metastases seen at conventional US (a) and after contrast media administration (b) 10 2 Surgical Treatment of Colorectal Liver Metastases. .. primary tumor stage Recurrences after resection of stage I or II cancer occurred significantly later than after resection of more advanced tumors 4 1 Surgical Treatment of Colorectal Liver Metastases 1.3 Natural History and Disease Therapy The natural history of untreated metastatic colorectal cancer is the standard against which the effectiveness of any treatment should be measured However, since in... (1997) Natural history of liver metastases from colo-rectal carcinoma J Gastrointest Surg 1:398–407 Stangl R, Altendorf-Hofmann A, Charnley RM et al (1994) Factors influencing the natural history of colorectal liver metastases Lancet 343:1405–1410 Wagner JS, Adson MA, Adson MH et al (1984) The natural history of hepatic metastases from colorectal cancer A comparison with resective treatment Ann Surg 199:502–507... 2.3.2 Imaging Findings The majority of colorectal liver metastases are solid hypovascular lesions In the portal-venous phase, metastases become more conspicuous as lesions that are hypodense compared to normal liver Late arterial phase imaging has been reported to improve lesion characterization of colorectal liver metastases, particularly lesions < 1 cm in diameter Liver metastases may have a peripheral,... T2-weighted imaging Surgical Treatment of Colorectal Liver Metastases 16 2 a c b d Fig 2 9 Liver metastases (red arrows) detected after injection of gadoxate (Primovist), an extracellular and hepatobiliary contrast agent: (a) arterial phase, (b) portal-venous phase, (c) late venous phase, and (d) hepatobiliary phase Lesion-to -liver contrast is improved in the last phase DWI, colorectal hepatic metastases show... surgical resection of liver metastases, by detecting small lesions not shown at CT scan In 2004, Bartolozzi et al [30] presented the results of a prospective, multi-institutional trial whose primary end-point was to compare the sensitivity of unenhanced and mangafodipir enhanced Surgical Treatment of Parkinson’s Disease and Other Movement Disorders HUMANA PRESS Surgical Treatment of Parkinson’s Disease and Other Movement Disorders EDITED BY Daniel Tarsy, MD Jerrold L. Vitek, MD , P h D Andres M. Lozano, MD , P h D EDITED BY Daniel Tarsy, MD Jerrold L. Vitek, MD , P h D Andres M. Lozano, MD , P h D HUMANA PRESS Surgical Treatment of Parkinson’s Disease and Other Movement Disorders C URRENT CLINICAL NEUROLOGY Daniel Tarsy, MD, SERIES EDITORS The Visual Field: A Perimetric Atlas, edited by Jason J. S. Barton and Michael Benatar, 2003 Surgical Treatment of Parkinson’s Disease and Other Movement Disorders, edited by Daniel Tarsy, Jerrold L. Vitek, and Andres M. Lozano, 2003 Myasthenia Gravis and Related Disorders, edited by Henry J. Kaminski, 2003 Seizures: Medical Causes and Management, edited by Norman Delanty, 2002 Clinical Evaluation and Management of Spasticity, edited by David A. Gelber and Douglas R. Jeffery, 2002 Early Diagnosis of Alzheimer's Disease, edited by Leonard F. M. Scinto and Kirk R. Daffner, 2000 Sexual and Reproductive Neurorehabilitation, edited by Mindy Aisen, 1997 Surgical Treatment of Parkinson’s Disease and Other Movement Disorders Edited by Daniel Tarsy, MD Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Jerrold L. Vitek, MD, PhD Emory University School of Medicine, Atlanta, GA and Andres M. Lozano, MD, PhD Toronto Western Hospital, Toronto, ON, Canada Humana Press Totowa, New Jersey © 2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All authored papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manu- facturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual pa- tients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Adminis- tration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. ∞ ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials. Cover illustration: T2-weighted axial sections used to identify coordinates Surgical Treatment of Parkinson’s Disease and Other Movement Disorders HUMANA PRESS Surgical Treatment of Parkinson’s Disease and Other Movement Disorders EDITED BY Daniel Tarsy, MD Jerrold L. Vitek, MD , P h D Andres M. Lozano, MD , P h D EDITED BY Daniel Tarsy, MD Jerrold L. Vitek, MD , P h D Andres M. Lozano, MD , P h D HUMANA PRESS Surgical Treatment of Parkinson’s Disease and Other Movement Disorders C URRENT CLINICAL NEUROLOGY Daniel Tarsy, MD, SERIES EDITORS The Visual Field: A Perimetric Atlas, edited by Jason J. S. Barton and Michael Benatar, 2003 Surgical Treatment of Parkinson’s Disease and Other Movement Disorders, edited by Daniel Tarsy, Jerrold L. Vitek, and Andres M. Lozano, 2003 Myasthenia Gravis and Related Disorders, edited by Henry J. Kaminski, 2003 Seizures: Medical Causes and Management, edited by Norman Delanty, 2002 Clinical Evaluation and Management of Spasticity, edited by David A. Gelber and Douglas R. Jeffery, 2002 Early Diagnosis of Alzheimer's Disease, edited by Leonard F. M. Scinto and Kirk R. Daffner, 2000 Sexual and Reproductive Neurorehabilitation, edited by Mindy Aisen, 1997 Surgical Treatment of Parkinson’s Disease and Other Movement Disorders Edited by Daniel Tarsy, MD Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Jerrold L. Vitek, MD, PhD Emory University School of Medicine, Atlanta, GA and Andres M. Lozano, MD, PhD Toronto Western Hospital, Toronto, ON, Canada Humana Press Totowa, New Jersey © 2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All authored papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manu- facturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual pa- tients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Adminis- tration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. ∞ ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials. Cover illustration: T2-weighted axial sections used to identify coordinates Apostolakis et al. Journal of Cardiothoracic Surgery 2010, 5:43 http://www.cardiothoracicsurgery.org/content/5/1/43 Open Access CASE REPORT BioMed Central © 2010 Apostolakis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Com- mons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. Case report Postoperative peri-axillary seroma following axillary artery cannulation for surgical treatment of acute type A aortic dissection Efstratios E Apostolakis* 1 , Nikolaos G Baikoussis 1 , Konstantinos Katsanos 2 and Menelaos Karanikolas 3 Abstract The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options. Introduction The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dis- section remains controversial [1-3]. Avoidance of femoral artery cannulation may reduce the risk of retrograde embolic events from atheromatous debris in the thoracic and abdominal aorta, but direct ascending aorta cannula- tion can be complicated by the presence of thrombus or atheromatous debris [4,5]. Right axillary artery cannula- tion provides antegrade arterial perfusion during CPB and allows continuous antegrade cerebral perfusion dur- ing hypothermic circulatory arrest, thereby minimizing global cerebral ischemia [3,4]. However, right axillary artery cannulation has been associated with serious com- plications, including malperfusion problems during CPB, compromised postoperative patency of the axillary artery (due to stenosis, thrombosis or dissection) and brachial plexus injury[6,7]. Perigraft seroma is a rare complication in vascular surgery and, to our knowledge, has not been reported after axillary artery cannulation. We herein describe the case of a 36 year old man with Marfan syn- drome and acute aortic dissection, who had right axillary artery cannulation for aortic root and ascending aorta replacement, and postoperatively developed a seroma in the right suclavian area. Case presentation A 36 year-old Caucasian man with Marfan syndrome was emergently admitted to our hospital with diagnosis of acute type A aortic dissection. Transthoracic echocar- diography and computed tomography revealed aortic valve regurgitation and aortic dissection extending from the root of the aorta to the iliac arteries. The dissection extended into the arch vessels, involving mainly the innominate and axillary artery (figure 1, 2). The patient underwent the Bentall procedure under CPB instituted through direct right axillary artery cannulation, without interposition of an anastomotic graft. We did not ... can thiệp sớm ) • • • • • • • • • Surgical era 19 84 1989: 80 (26) 1990–1999: 151 (50) 2000–20 04: 74 ( 24) Arch repair technique Sternotomy 74 ( 24) End-to-side anastomosis 58 (78) Extended... Nemoto EM Regional perfusion of the brain during neonatal aortic arch reconstruction J Thorac Cardiovasc Surg 1999; 117 : 1023–10 24 Potential Cx of Surgery : Change in arch geometry • Early : airway... (7–272) Median time on bypass (min) 1 34 ( 34 340 Neonatal aortic arch surgery results: literature summary Gargiulo G et al MMCTS 2007;2007:mmcts.2006.002 345 One stage repair owes • Tissue to tissue