Efstathios G. Lykoudis

Tapia’s Syndrome: An Unexpected but Real Complication of Rhinoplasty: Case Report and Literature Review

Extracranial involvement of the recurrent laryngeal and hypoglossal nerves, also known as Tapia’s syndrome, is a rare complication of airway management under general anesthesia. We report such a case after an otherwise uncomplicated rhinoplasty. After reviewing the other nine reported cases of Tapia’s syndrome, we found that half of the patients had undergone rhinoplasty or septorhinoplasty. The risk factors, etiology, clinical course, recovery potential, and preventive measures are analyzed and discussed. Although Tapia’s syndrome after rhinoplasty/septorhinoplasty appears to be rare, it should be considered by both the anesthetist and the plastic surgeon, and most importantly, special attention should be paid to preventive strategies.

One-stage reconstruction of the complex midfoot defect with a multiple osteotomized free fibular osteocutaneous flap: case report and literature review.

Complex midfoot defects represent a reconstructive challenge since midfoot plays a key role in standing and gait. We report the case of a 27‐year‐old patient with a complex midfoot defect due to a high‐energy gun shot injury. The defect included the tarsometatarsal complex, all three arches of the foot, and the overlying dorsal skin of the foot. Reconstruction was achieved in a single stage with a free fibular osteocutaneous flap. The fibula was osteotomized into three segments, which were used to reconstruct the bone defects, while the skin paddle of the flap was used for stable soft tissue coverage of the reconstructed bony skeleton. Early and late postoperative periods were uneventful. Bone incorporation was radiographically evident at 12 weeks, and full weight bearing was possible at 6 months postop. Final follow up, at 2 years postop, showed a very good functional and esthetic outcome.

Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end-to-side neurorrhaphy: a case report and literature review.

Reconstruction of weight‐bearing plantar defects remains a challenge due to the unique characteristics of the plantar skin and thus the limited available options. The medial plantar flap, either pedicled or free, represents an ideal option, but its use as sensate flap for forefoot defects has been scarcely reported. We present a case of plantar forefoot reconstruction with a free sensate medial plantar flap, with end‐to‐side coaptation of the cutaneous sensory fascicles of the flap to the medial plantar nerve of the recipient. Last follow‐up, at 2 years post‐op, verified a very good functional and aesthetic outcome, indicating that the suggested approach may prove the treatment of choice in selected cases of plantar forefoot reconstruction.

Microvascular repair following a modified crush-avulsion injury in a rat model: Effect of recombinant human tissue-type plasminogen activator on the patency rate

The failure rate of replantations following a crush‐avulsion type injury is high. This study has been designed to reproduce an effective standardized crush‐avulsion injury model to the femoral artery of the rat and evaluate the antithrombotic efficacy of systemic intravenous administration of recombinant human tissue‐type plasminogen activator (rt‐PA). The crush‐avulsion injury was reproduced by using a bulldog clamp and two hemostats and followed by microvascular repair. The animals were divided into three groups of 20 rats each and received either normal saline, heparin 100 U/kg body weight, or rt‐PA 3.5 mg/kg body weight intravenously. Patency tests were performed 20 min and 48 h after blood flow reestablishment. Results showed that this experimental crush‐avulsion injury model ensures low patency in the control group, whereas systemic rt‐PA administration improves the patency rate statistically significantly compared to control and heparin groups at both 20 min and 48 h postrevascularization.

Combination treatment of TRAIL, DFMO and radiation for malignant glioma cells.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) has shown potent and cancer-selective killing activity and drawn considerable attention as a promising therapy for cancer. Another promising cancer therapy is difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase, which is oraly administered and well tolerated. Nevertheless, many types of cancer, including gliomas, have exhibited resistance to TRAIL-induced apoptosis and similarly the potency of DFMO should be enhanced to optimize therapeutic efficacy. In this study we sought to determine whether DFMO, in combination with TRAIL and radiation, could result in an enhanced anti-glioma effect in vitro. We investigated the effect of DFMO, TRAIL and radiation in various combinations on a panel of glioblastoma cell lines (A172, T98G, D54, U251MG). Viability and proliferation of the cells were examined with trypan blue exclusion assay, crystal violet and xCELLigence system. Apoptosis (Annexin-PI), cell cycle and activation of caspase-8 were tested with flow cytometry. BAD protein levels were determined by Western blot analysis. DFMO induced BAD overexpression. Combination treatment with DFMO, TRAIL and radiation significantly reduced cell viability in all cell lines tested. Increased induction of cell death and cell cycle arrest was confirmed with flow cytometry in A172 and D54 cell lines, while enhanced activation of annexin and caspase-8 was revealed in U251MG and T98G cells. The treatment of glioblastoma cell lines with combination of DFMO, TRAIL and radiation showed an enhanced effect. This combination treatment may represent a novel strategy for targeting glioblastoma.

Effect of Visible and Infrared Polarized Light on the Healing Process of Full-Thickness Skin Wounds: An Experimental Study

OBJECTIVE AND BACKGROUND DATA Polarized light has already been experimentally and clinically used in an effort to promote wound healing, but the findings have been equivocal. The aim of this study was to evaluate the effect of visible and infrared polarized light of a specific range of wavelength (580-3400 nm) on the secondary healing of full-thickness skin wounds in rats. MATERIALS AND METHODS Forty male Wistar rats were used, divided in two groups of 20 animals each. A standardized open full-thickness skin wound was created on the back of each animal. In the first group the rats were exposed to polarized light (40 mW/cm(2) and 2.4 J/cm(2)) for 7 min on a daily basis (total daily dose = 16.8 J/cm(2)), while the second group acted as controls. Clinical and histological evaluation of wound healing were performed on days 5, 10, 15, and 20 post-wound. The size of the wounds was measured with the use of planimetry, whereas epithelialization, inflammatory response, neovascularization, and collagen formation were histologically assessed. RESULTS According to our findings, the group exposed to light therapy showed statistically significantly faster epithelialization seen on days 10 and 15 post-wound compared to controls, as well as better quality of the healing process (although not statistically significantly) at all time points. CONCLUSION In conclusion, this specific fraction of polarized light seems to have beneficial effects on wound healing, leading to faster epithelialization and qualitatively better wound healing.

The conjoint medial circumflex femoral perforator and gracilis muscle free flap: anatomical study and clinical use for complex facial paralysis reconstruction.

Background: The aim of this study was to establish the anatomic basis of the conjoint medial circumflex femoral perforator and gracilis muscle flap and to expand the use of this flap in complex facial paralysis reconstruction. Methods: An anatomic study was initially undertaken to record the existence, consistency, and diameter of musculocutaneous perforators emanating from the proximal third of the gracilis muscle to provide blood supply to the overlying fascia, subcutaneous fat, and skin. In a total of 20 clinical cases of gracilis muscle harvesting, the aforementioned anatomical data were recorded during flap dissection. At least one musculocutaneus perforator, consisting of one artery and two accompanying veins (vein caliber > 0.3 mm) was found in 95 percent of cases. Results: The anatomical study was followed by successful use of the conjoint flap for reconstruction of longstanding facial palsy accompanied by a soft-tissue defect of the cheek. In the first stage, cross-face nerve grafting was performed. In the second stage, free transfer of the conjoint flap, consisting of the proximal third of the gracilis muscle and the overlying subcutaneous fat, was performed to the face. The only connection between the two components of the conjoint flap was one musculocutaneous perforator. When the flap was inset, the muscle was used for facial reanimation and partial obliteration of the soft-tissue defect, while the subcutaneous fat was used to obliterate the rest of the defect Conclusion: The proposed technique ensured symmetry of the face, on both rest and animation, and obliteration of the cheek deformity.

From Clinical Standards to Translating Next-Generation Sequencing Research into Patient Care Improvement for Hepatobiliary and Pancreatic Cancers

Hepatobiliary and pancreatic (HBP) cancers are associated with high cancer-related death rates. Surgery aiming for complete tumor resection (R0) remains the cornerstone of the treatment for HBP cancers. The current progress in the adjuvant treatment is quite slow, with gemcitabine chemotherapy available only for pancreatic ductal adenocarcinoma (PDA). In the advanced and metastatic setting, only two targeted drugs have been approved by the Food & Drug Administration (FDA), which are sorafenib for hepatocellular carcinoma and erlotinib for PDA. It is a pity that multiple Phase III randomized control trials testing the efficacy of targeted agents have negative results. Failure in the development of effective drugs probably reflects the poor understanding of genome-wide alterations and molecular mechanisms orchestrating therapeutic resistance and recurrence. In the post-ENCODE (Encyclopedia of DNA Elements) era, cancer is referred to as a highly heterogeneous and systemic disease of the genome. The unprecedented potential of next-generation sequencing (NGS) technologies to accurately identify genetic and genomic variations has attracted major research and clinical interest. The applications of NGS include targeted NGS with potential clinical implications, while whole-exome and whole-genome sequencing focus on the discovery of both novel cancer driver genes and therapeutic targets. These advances dictate new designs for clinical trials to validate biomarkers and drugs. This review discusses the findings of available NGS studies on HBP cancers and the limitations of genome sequencing analysis to translate genome-based biomarkers and drugs into patient care in the clinic.

The Role of Fast Cell Cycle Analysis in Pediatric Brain Tumors.

Cell cycle analysis by flow cytometry has not been adequately studied in pediatric brain tumors. We investigated the value of a modified rapid (within 6 min) cell cycle analysis protocol for the characterization of malignancy of pediatric brain tumors and for the differentiation of neoplastic from nonneoplastic tissue for possible intraoperative application. We retrospectively studied brain tumor specimens from patients treated at our institute over a 5-year period. All tumor samples were histopathologically verified before flow-cytometric analysis. The histopathological examination of permanent tissue sections was the gold standard. There were 68 brain tumor cases. All tumors had significantly lower G₀/G1 and significantly higher S phase and mitosis fractions than normal brain tissue. Furthermore low-grade tumors could be differentiated from high-grade tumors. DNA aneuploidy was detected in 35 tumors. A correlation between S phase fraction and Ki-67 index was found in medulloblastomas and anaplastic ependymomas. Rapid cell cycle analysis by flow cytometry is a promising method for the identification of neoplastic tissue intraoperatively. Low-grade tumors could be differentiated from high-grade tumors. Thus, cell cycle analysis can be a valuable adjunct to the histopathological evaluation of pediatric brain tumors, whereas its intraoperative application warrants further investigation.

Complex calcaneal defect reconstruction with osteotomized free fibula-flexor hallucis longus osteomuscular flap.

Complex calcaneal defects represent a reconstructive challenge since calcaneous plays a key role in standing and gait. We report the case of a 35‐year‐old patient with a complex calcaneal defect due to chronic osteomyelitis after a high energy Gustillo type IIIB calcaneal fracture that was reconstructed with a free fibula–flexor hallucis longus osteomuscular flap. The fibula was osteotomized into two segments, which were used to reconstruct the bone defect, and the muscular component of the flap was used for coverage of the reconstructed calcaneal skeleton. Fifteen days later permanent skin coverage was ensured with a local random pattern rhomboid skin flap. Early and late postoperative periods were uneventful. Bone maturation was radiographically evident at a follow up of 12 weeks, and complete bone incorporation at 3 years. Full weight bearing was possible at 6 months postop. Final follow up, at 3 years postop, verified a very good functional and aesthetic outcome.