Deniz Dayicioglu

The Treatment of Gustilo Grade IIIB Tibia Fractures with Application of Antibiotic Spacer, Flap, and Sequential Distraction Osteogenesis

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope.The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12–77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5–17). Reconstruction time was 26.5 months (12–73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient.The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.

Traumatic peripheral nerve injury: a wartime review.

Incidence of peripheral nerve injury in extremity trauma is low, with reported rates of 1.5 to 2.8%; however there is significant associated morbidity and outcomes of peripheral nerve repair are poor, especially when delayed. In this article, we provide a brief review of pathophysiology, classification, and surgery of peripheral nerve injuries, with special emphasis on wartime injuries.

Recurrent Systemic Anaplastic Lymphoma Kinase-Negative Anaplastic Large Cell Lymphoma Presenting as a Breast Implant-Associated Lesion.

A woman aged 48 years presented with fevers, chills, weight loss, and night sweats. She had significant lymphadenopathy of the left neck as well as the left axilla. Her history was significant for bilateral breast augmentation with textured silicone implants more than 25 years ago. Excisional biopsy of a cervical lymph node revealed large, atypical cells positive for CD4 and CD30 and negative for Epstein-Barr virus-encoded ribonucleic acid, CD2, CD3, CD5, CD7, CD8, CD15, CD20, pan-keratin, S100, anaplastic lymphoma kinase (ALK), and paired box 5. These findings were consistent with Ann Arbor stage IIIB ALK-anaplastic large cell lymphoma (ALCL). The patient was started on 6 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone. She initially had no signs or symptoms of breast involvement; however, after developing seroma during the clinical course, the patient underwent capsulectomy and removal of the intact, textured silicone implants. Pathological evaluation demonstrated ALK-ALCL in the left breast capsule with cells displaying a significant degree of pleomorphism with binucleated forms and numerous mitoses. Fluorescence in situ hybridization confirmed the tumor was negative for t(2;5). She presented 8 weeks later showing evidence of recurrent systemic disease.

Fishing-Injury-Related Flexor Tenosynovitis of the Hand: A Case Report and Review

Hand infections occurring after fishing and other marine-related activities may involve uncommon bacteria that are not susceptible to the conventional or empiric antibiotic therapy used to treat soft tissue infections. Therefore appropriate treatment is often delayed and could lead to severe hand damage. An illustrative case of fishing-related injury leading to complicated tenosynovitis and horseshoe abscess caused by Mycobacterium marinum and its treatment course is outlined. Laceration of the skin during boating is fairly common. Because of the rarity of some of the bacteria, referrals to the appropriate specialist including hand surgeons and infectious disease specialists should occur in early stages. M. marinum infections should always be considered in injuries related to seawater and fishing as this may lead to early appropriate treatment and prevent severe damage.

Oncoplastic Surgery: Keeping It Simple With 5 Essential Volume Displacement Techniques for Breast Conservation in a Patient With Moderate- to Large-Sized Breasts

Oncoplastic surgery is an evolving field in breast surgery combining the strengths of breast surgical oncology with plastic surgery. It provides the surgeon the ability to excise large areas of the breast in the oncologic resection without compromising, and possibly improving, its aesthetic appearance. The purpose of this review is to provide a guide that could help a breast surgeon excise breast cancer in most areas of the breast using 5 oncoplastic techniques. These techniques would be used depending primarily on the location of the cancer in the breast and also on the size of the tumor.

Outcomes of Breast Reconstruction After Mastectomy Using Tissue Expander and Implant Reconstruction.

ObjectiveConsiderable attention has been given to patient-reported outcomes in breast reconstruction. The objective of this study is to evaluate the effect of postreconstruction change in breast volume on validated patient satisfaction survey scores. MethodsPatients undergoing skin-sparing mastectomy followed by tissue expander/implant reconstruction between July 2010 and July 2014 by a single surgeon were given postoperative patient-reported satisfaction surveys (BREAST-Q). Retrospective chart review of patients with completed surveys was undertaken to record patient characteristics and compare preoperative breast volume (extrapolated from mastectomy mass) with postoperative implant volume, and percent change in volume was calculated. Regressions were utilized to correlate percent change with satisfaction in each category. ResultsA total of 160 patient surveys were included. Sixty-five percent of breasts analyzed had increased volume after reconstruction, whereas 35% had decreased volume. The increased volume group had significantly lower body mass index (P = 0.0001) and was significantly younger (P = 0.009) than the decreased volume group. Patients who experienced increase in breast volume reported statistically greater satisfaction with breasts (P = 0.019), overall outcome (P = 0.012), sexual well-being (P = 0.002), and information (P = 0.042) compared with the decreased volume group. Moreover, linear regression revealed that as percent change increased, so did satisfaction with outcome (P = 0.02), sexual well-being (P = 0.005), information (P = 0.018), and surgeon (P = 0.036). Notably, there was not a significant difference in complication rate (P = 0.146) or tumor margin (0.914) between the groups. ConclusionPatients who undergo tissue expander/implant breast reconstruction with final implants that are larger in volume than their native breasts have increased patient satisfaction scores in several categories without increase in complication rate or difference in tumor margin. There is a positive linear relationship between percent change and patient satisfaction.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

BackgroundWomen who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. MethodsInstitutional review board–approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. ResultsFifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). ConclusionsImplant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

L-myc Polymorphism in Head and Neck Nonmelanoma Skin and Lower Lip Cancers

OBJECTIVE To evaluate the presence of L-myc gene variations as a genetic predisposition to head and neck nonmelanoma skin cancer (HNNMSC) and lower lip cancer (LLC). DESIGN A case-control study. SETTING An academic institute laboratory. PARTICIPANTS Twenty-four patients with HNNMSC and 27 with LLC were compared with 51 age- and sex-matched control subjects. MAIN OUTCOME MEASURES Polymerase chain reaction restriction fragment length polymorphism and agarose gel electrophoresis were used to determine the L-myc oncogene genotypes. RESULTS The presence of the LS genotype was found to be significantly increased in the study group, whereas the LL genotype was not detected. The S allele was also more frequent in the study group. The SS genotype was found to correlate with aggressive tumor behavior in patients with HNNMSC and a family history of cancer. Patients with LLC displayed significantly less of the SS genotype. CONCLUSIONS The L-myc gene polymorphism may help detect and prevent HNNMSC and LLC in susceptible individuals. It may also contribute to estimation of tumor behavior in patients with HNNMSC.

Vascular anomalies of the upper extremity in children.

Vascular malformations in the pediatric upper extremity remain a diagnostic and therapeutic challenge. Recent knowledge about diagnosis and treatment is provided including specific markers, imaging techniques, and management.

Outcomes of Breast Reconstruction After Mastectomy Using Deep Inferior Epigastric Perforator Flap After Massive Weight Loss.

BackgroundBecause of the correlation between breast cancer and obesity, plastic surgeons may encounter patients requiring reconstructive breast surgery after massive weight loss (MWL). Use of redundant abdominal skin for deep inferior epigastric artery perforator (DIEP) flap in these patients is a novel concept whose value has not been adequately studied. ObjectiveAssess the outcomes of the DIEP technique for breast reconstruction in the massive weight loss population. PatientsFrom 103 breast reconstruction patients having 150 DIEP flap procedures, 9 DIEP flaps were performed in MWL patients. Propensity score matching was used in a 1:2 ratio. Eighteen nonweight loss (NWL) patients were selected for comparison with 9 DIEP flaps performed in 6 MWL patients. MeasurementsPatients in 2 groups were matched for age and body mass index (BMI). Massive weight loss patients were compared with NWL patients on the basis of immediate versus delayed reconstruction and history of radiation; DIEP flap characteristics, including coupler size, additional venous anastomosis, need for re-exploration, and flap loss; length of hospital stay; abdominal wound healing complication; and hernia or bulging. ResultsThere was no difference in the incidence of flap failures, bulging, or hernias requiring surgery in the MWL group. Additionally, there was no statistical difference in flap survival, abdominal complications, hospitalization days, operative time, or operative characteristics between the 2 groups. There was a significant positive correlation between immediate wound healing complications and comorbidities (P = 0.041). However, there was no correlation between wound healing complications and weight loss history. LimitationsOnly 6 MWL patients of a single surgeon were studied. ConclusionsFor breast reconstruction after mastectomy, DIEP flaps can be used in MWL and NWL populations with equal flap success and abdominal donor site results. Therefore, cosmetic surgeons performing contouring procedures should consider sparing redundant abdominal tissues in patients requiring breast reconstruction.