Treatment of Candida sternal infection following cardiac surgery - a review of literature.

BACKGROUND: Candida sternal wound infections (SWIs) following cardiac surgery are rare but are associated with a high mortality rate. Guidelines on this topic either propose no suggestions for management or offer recommendations based on a small number of reports. METHODS: This paper presents a case of a Candida SWI and its successful treatment with debridement using a burr, negative pressure vacuum therapy (NPVT) and dermal grafting. To investigate different methods of treating Candida SWIs following cardiac surgery, a review was completed using the MEDLINE database. Reports without English abstracts and without defined outcomes of therapy for individual patients were excluded. RESULTS: Seventy-seven cases of Candida SWIs following cardiac surgery were identified in 20 articles published since 1999, including our case. Treatment strategies are identified: omentum flap; muscle flap; debridement and secondary wound healing with or without NPVT; debridement and primary closure; incision and drainage; only medical therapy. Patients documented in the articles were classified based on the following outcomes: cured (n = 41 patients [including the present case]), relapse infection (n = 25 patients) and death (n = 11 patients). The various methods used to treat patients were analysed. CONCLUSIONS: Delayed closure reoperation with surgical debridement and NPVT have favourable outcomes. In the presence of widespread osteomyelitis, the use of omental flaps is advocated. Treatment with muscle flaps has a high rate of relapse. Debridement and secondary healing or conservative management with antifungals alone can be considered in the treatment of relapsing infection.

Medial Rectus Muscle Injuries after Functional Endoscopic Sinus Surgery.

In recent years, functional endoscopic sinus surgery (FESS) has improved the treatment of sinus disorders. However, various orbital complications have been reported, including optic nerve damage, orbital hemorrhage, infection, lacrimal drainage system injury, and strabismus. Complications are rare but may cause severe morbidity. We describe two patients who underwent endoscopic sinus surgery procedures that resulted in trauma to the medial rectus muscle. The first patient had medial rectus paresia due to contusional trauma and showed spontaneous resolution in a month. The other patient had an orbital medial wall defect with medial rectus injury and he underwent orbitotomy. Medial rectus innervation returned at postoperative 8 months. Several extraocular muscles may be traumatized during FESS. Timing and method of treatment are based on the severity and type of injury and the number of muscles involved. Treatment strategies are dependent on accurate interpretation of magnetic resonance imaging scans.

Adipose-Derived Stem Cells Improve Survival of Random Pattern Cutaneous Flaps in Radiation Damaged Skin.

BACKGROUND: Tissue ischemia and necrosis following surgery after radiotherapy on the skin and subcutaneous tissue are well known to all reconstructive surgeons. Nevertheless, there has been no report so far on local effects of adipose-derived stem cells (ADSCs) on random flap survival elevated in an irradiated rat dorsum. In this experimental study, we aimed to identify the effect of adipose tissue-derived stem cell injection on random flap survival in irradiated tissues. METHODS: Adipose-derived stem cells were isolated from the groin region of Sprague-Dawley rats and expanded ex vivo for 3 passages. Animals were divided into 2: irradiated and nonirradiated and then again into ADSC injected and noninjected groups altogether 4 groups. After elevation of caudally based dorsal random skin flaps (10  cm long and 3  cm wide), Green fluorescent protein labeled ADSCs were then injected to the base of the pedicle. Radiotherapy was 20  Gy single dose applied during 8 weeks before surgery. At postoperative day 7, flap viability measurement and tissue harvest for histologic and immunocytochemical assessment were performed in all groups. RESULTS: We have observed increased flap viability in ADSCs injected irradiated group compared with control radiation group with small but not statistically significantly increase in vessel count per field. Mean survival rate of the flaps in groups A, B, C, and D were 40.46%, 60.07%, 40.90%, and 56.13%, respectively. There was a statistically significant vessel count difference between group B and group A and also with group D (P < 0.001). CONCLUSIONS: These findings suggest that ADSCs have a potential for enhancing the blood supply of random pattern skin flaps after radiation injury. This mechanism might be both neovascularization and vasodilation along with endothelial repair. Further studies are needed.

Acellular Dermal Matrix Use in Cleft Palate and Palatal Fistula Repair: A Potential Benefit?

BACKGROUND: In cleft palate repair, anatomically oriented, tension free, atraumatic total closure is the key to achieve a normal speech consecutive to a sufficient velopharyngeal closure and also to prevent postoperative fistula development. In this clinical study, we review our experience with acellular dermal matrix (ADM) which was used as an adjunct to facilitate difficult cleft palate and palatal fistula closure. METHODS: From October 2009 till December 2013, primary cleft palate and fistula repairs in which ADM was used were culled from the cleft surgery files. Acellular dermal matrix was used as an extra layer in between palatal flaps of primary repairs and as a sandwiched sheet separating the flaps used to repair fistulas. In addition to patient, cleft and fistula demographics, records were evaluated for sizes, fistula development, fistula recurrence, extrusion, exposure, and infection. RESULTS: Acellular dermal matrix was used in 35 patients with palatal clefts of mean size 15 ±â€Š4  mm and in 15 palatal fistulas. Two-flap palatoplasty technique was the dominant technique for the palate repair. Fistula rate for the palate repair was 8.5% and fistula recurrence rate was 20%. Mean follow-up for the palate and fistula repair patients was 29 ±â€Š15 months and 32 ±â€Š11 months, respectively. In two cases of palatoplasty group and in four cases of fistula repair group, ADM was exposed resulting in total extrusion in two fistula cases. CONCLUSIONS: In this ongoing experience of application, ADM has been shown to be a simple, safe, and helpful tool to reduce fistula rate mainly in relatively wide and high tension tenuous cleft palate repairs but less favorable in challenging fistula closure attempts particularly along with poorly vascularized surrounding tissues. However, study design and its results are yet far from strongly recommending routine ADM use in cleft palate surgery.

Spontaneously reduced isolated orbital roof fracture.

We report a case of a spontaneously reduced isolated orbital roof blow-in fracture with resolution of associated diplopia and blepharoptosis highlighting the need for a low threshold for reimaging this cohort of facial fracture patients.

Use of inferior gluteal artery and posterior thigh perforators in management of ischial pressure sores with limited donor sites for flap coverage.

BACKGROUND: Reconstructive surgery for ischial pressure sore defects presents a challenge because of high rates of recurrence. The aim of this study was to describe the use of inferior gluteal artery (IGA) and posterior thigh perforators in management of ischial pressure sores with limited donor sites. PATIENTS AND METHOD: Between September 2005 and 2009, 11 patients (9 male, 2 female) with ischial sores were operated by using IGA and posterior thigh perforator flaps. The data of patients included age, sex, cause of paraplegia, flap size, perforator of flap, previous surgeries, recurrences, complications, and postoperative follow-up. RESULTS: Nine IGA and 5 posterior thigh perforator flaps were used. Six patients presented with recurrent lesions, 5 patients were operated for sacral and contralateral ischial pressure sores previously. In 2 patients, IGA and posterior thigh perforator flaps were used in combination. Patients were followed for an average of 34.3 months. In 2 recurrent cases, readvancement of IGA perforator flap and gluteus maximus myocutaneous flap were treatment of choice. CONCLUSION: Treatment of patients with recurrent lesions or multiple pressure sores is challenging because of limited available flap donor sites. In this study, posterior thigh perforator flaps were preferred in patients in whom the previous donor site was the gluteal region. IGA perforator flaps were the treatment of choice in patients for whom posterior thigh region was previously used. Alternately, preserved perforators of previous conventional myocutaneous flaps enabled us to use these perforators in recurrences.

Fournier's gangrene in childhood: a report of 3 infant patients.

Fournier's gangrene is uncommon in pediatric age group, and little is known about the disease in the newborn period and infancy. Three patients, aged 10 days, 14, and 17 months, with Fournier's gangrene, were treated in our hospital. The predisposing factors were prematurity, a diaper rash, and varicella infection, respectively. Especially, prematurity and diaper rash are rare predisposing factors in the pediatric population; therefore, high index of suspicion, prompt diagnosis, conservative surgery, and multidisciplinary approach are the mainstays of management in children with Fournier's gangrene.

[Odontogenic and nonodontogenic jaw cysts: experience in 25 cases]. / Cenenin odontojenik ve odontojenik olmayan kistleri: 25 olguda deneyimlerimiz.

OBJECTIVES: We retrospectively evaluated the patients with jaw cysts treated at our center. PATIENTS AND METHODS: The study included 25 patients (14 males, 11 females; mean age 33+/-19 years; range 7 to 69 years) who underwent surgery for odontogenic or nonodontogenic jaw cysts. RESULTS: The most common presentation was a swelling in the jaw with or without dental problems. Involvement was in the mandible in 18 patients, and in the maxilla in seven patients. The lesions consisted of eight radicular, six dentigerous, two nasoalveolar, two globulomaxillary cysts, and three keratocysts. Four patients had gingival, nasopalatine, residual, and median mandibular cysts, respectively. Marsupialization, curettage, extensive burring, enucleation, or marginal resection were performed depending on pre- and intraoperative findings. The defects were repaired with a corticocancellous iliac bone block graft in three patients and cancellous iliac bone chips in five patients. During a mean follow-up of 14 months (range 12 to 46 months), recurrence was seen in only one patient with a keratocyst. CONCLUSION: A good preoperative assessment, complete removal of the cystic lesion, and close radiographic follow-up are essential for a successful outcome in jaw cysts. In selected cases, reconstruction of the defects with autogenous corticocancellous iliac bone graft yields highly satisfactory results.

Effects of hyperbaric oxygen therapy on fibrovascular ingrowth in porous polyethylene blocks implanted under burn scar tissue: an experimental study.

Effects of hyperbaric oxygen (HBO) therapy on biointegration of porous polyethylene (PP) implanted beneath dorsal burn scar and normal skin were experimentally examined in Sprague-Dawley rats. In Group One (n=20), daily HBO treatments were given after the implantation of PP material under dorsal burn scar, whereas, in Group Two (n=20) no treatment was given following the same surgical procedure. In Group Three (n=20), PP was placed under dorsal normal skin and subsequently HBO therapy protocol was applied while Group Four (n=20) stayed without HBO treatment after the implantation. One, 2, 3 and 4 weeks after the implantations, sections were respectively taken from five rats from each group. Biointegration process and effects of HBO therapy were evaluated microscopically and the ratio of fibrovascular ingrowth (FVI) was determined for each rat. The results showed significantly superior FVI in Group One compared to Group Two and again FVI into PP under normal skin treated with HBO revealed better results against Group Four (p<0.05). Well-vascularized capsule formation and tissue integration was delayed both in Group Two and in Group Three in the first 3 weeks. In conclusion, HBO therapy enhances biointegration of PP in hypoxic burn scar areas via improving collagen synthesis and neovascularization; otherwise, it apparently delays tissue ingrowth into porous structure implanted in normal healthy tissues.

Extra-skeletal Ewing's sarcoma of the submandibular gland.

Extra-skeletal Ewing's sarcoma (EES) is an uncommon malignancy, especially in the head and neck region that may arise in various extra-osseous tissues. We report a 22-year-old male with an EES of the submandibular gland, which to the best of our knowledge, has not been described previously. The patient who underwent combined treatment with surgical resection and chemo-irradiation was disease free for 22 months but succumbed to multi-organ metastases 14 months later. This case highlights the combined diagnostic role of immunohistochemical, cytogenetic and radiological evaluation of EES. EES is an aggressive cancer that requires multidisciplinary management with wide surgical excision and adjunctive chemo-irradiation for the best outcome.

Report of a radiation-induced leiomyosarcoma arising from the posterior neck.

Radiation-induced leiomyosarcoma of the head and neck region has been very seldom described. Herein, we report a 48-year-old male patient who developed leiomyosarcoma in his posterior neck region, which was previously radiated due to a cerebellar astrocytoma.

W(h)ither orbital pseudotumor?

Orbital pseudotumor is a nonspecific, idiopathic benign inflammatory process characterized by a polymorphous lymphoid infiltrate with varying degrees of fibrosis. We retrospectively reviewed the clinical presentation, management, and progress of six consecutive patients referred to our service with an initial diagnosis of orbital pseudotumor to underscore the challenge and pitfalls in managing this group of patients. Three male and three female patients, aged 27 to 74 years, presented with a variety of ophthalmologic problems, including orbital swelling, chemosis, proptosis, blepharoptosis, restricted eye motion, diplopia, and visual loss. The initial diagnosis of orbital pseudotumor was based on clinical findings, results of routine laboratory screening tests, computed tomographic and/or magnetic resonance imaging scans, and the response to corticosteroid treatment in three patients. In these three patients, the final diagnosis of orbital pseudotumor was confidently made only in one patient who remained in remission after corticosteroid therapy. The remaining two patients had Miller-Fisher syndrome and thyroid ophthalmopathy. Three other patients initially diagnosed with orbital pseudotumor underwent biopsy through an orbitotomy with comprehensive histopathologic evaluation. Two of these patients were subsequently diagnosed with non-Hodgkin lymphoma. Orbital pseudotumor belongs to a spectrum of lymphocytic infiltrative orbital conditions. It is a diagnosis of exclusion. The initial diagnosis must be regarded as provisional, and failure of complete resolution with corticosteroid therapy should heighten the index of suspicion and a biopsy should be considered. However, diagnosis may be difficult even with comprehensive histopathologic studies.

Distally based posterior interosseous flap: primary role in soft-tissue reconstruction of the hand.

A series of 15 consecutive patients with various hand defects requiring flap coverage was reviewed in this study. The defects were all covered with the distally based posterior interosseous flap. Its main indications were in complex hand trauma, severe burn injury, or skin cancer ablation, either acute or postprimary. In 12 of the patients, flaps survived completely. In 3 patients, there was partial necrosis of the distal part of the flap, which did not require additional surgical procedure. Radial nerve palsy was noted in one of the cases, with a complete recovery after 3 months. Donor site was closed directly in up to 4-cm-wide flaps, while larger flaps required skin grafting. No major anatomic variation was observed. Distally based posterior interosseous flap is a reliable choice for various types and areas of hand defects, with very low donor-site morbidity, and should be more commonly considered in clinical practice.

Extended lateral supramalleolar flap for very distal foot coverage: a case with arteriovenous malformation.

Arteriovenous malformation of the foot is very uncommon, and surgical closure after its treatment with embolization and total excision may be challenging for the foot surgeon, particularly in distally localized lesions. A popular method to cover these difficult wounds is free-tissue transfer, which is a highly demanding procedure. Alternatively, distally based regional flaps have been occasionally reported for clinical use in such distant foot defects. Herein, we present a 36-year-old female patient with a diagnosis of arteriovenous malformation arising in the distal medial plantar and dorsal surfaces of the right foot. After surgical resection of the vascular lesion preceded by a misapplied embolization procedure, an extended lateral supramalleolar flap was successfully transferred to the defect area, covering it completely. Functional and aesthetic outcome was satisfactory after 6 months follow-up. Extended lateral supramalleolar flap is a useful and reliable choice for distal foot reconstructions.

Triple Z flap technique for reconstruction of triangular defects in problem areas.

BACKGROUND: Reconstruction of defects close to important structures where standard flaps cannot easily be used may sometimes challenge surgeons. Classic reconstructive options for such defects close to problem areas may not always yield the best result. METHODS: The authors used the triple Z flap technique for triangular defects close to problem areas in 18 patients. The defects were triangular or close to triangular in shape, and three Z flaps were planned on each side of the defect. Flaps were transposed and the defects were reconstructed without any complications. RESULTS: The results were quite satisfying for both the patient and the surgeon. Neither retraction nor any distortion was observed. CONCLUSION: The triple Z flap technique can be used in selected cases where local flap choices are scarce and it is difficult to achieve good anatomical and aesthetic results.

A simple and effective procedure for treating burn contractures: releasing incision and quadra Z technique.

Burn contractures particularly involving the joints are challenging problems which might cause severe functional impairments. Many surgical techniques have been described for use, however, an ideal method yet to be found. Releasing incision is the most common and effective way to release the wide and severe contractures but it has some drawbacks. We propose a releasing incision technique combined with four Z plasty incisions to overcome the disadvantages of traditional releasing incision technique. We successfully used our releasing incision and quadra Z technique on seven consecutive patients with burn contractures between 2003 and 2005. We modified the classical releasing incision technique by adding four Z plasties; two of them with a common base on each corner of the incision line. In this technique, limitation of the webbing following the incision is made possible by the transposed flaps and unnecessary lateral extension of the incision and the defect was avoided, i.e. maximum release gain with minimal defect was provided. Satisfactory results were achieved in seven patients treated with this technique due to significant burn contractures between 2003 and 2005 with no significant complication. We propose this technique is suitable in all patients with severe burn contractures who require releasing incision and grafting.