[PRESSURE ULCER TREATMENT EXPERIENCE AT CLINICAL DEPARTMENT OF PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY, DUBRAVA UNIVERSITY HOSPITAL: COMPARISON OF RESULTS RECORDED IN THE 2011-2016 AND 2003-2008 PERIOD].

Results of this clinical study on surgical treatment of pressure ulcers at Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital showed that there was no difference between the 2011-2016 and 2003-2008 periods, indicating continuation of good surgical treatment planning and appropriate postoperative care. Despite the smaller number of hospitalized patients in the 2011-2016 period (31 patients and 42 reconstructive procedures), the number of reconstructive procedure was similar to the recent 2003-2008 period (47 patients and 57 reconstructive procedures). The best results of reconstruction of sacral region pressure ulcer were achieved with fasciocutaneous and musculocutaneous flaps. Whenever possible, depending on the extent of the defect, musculocutaneous flaps should be preferred for reconstruction. It is especially suitable for pressure ulcer recurrence. For ischial region reconstruction, good results can be obtained by mobilizing the semimembranosus and/or semitendinosus in defect gap. For trochanteric region, the tensor fascia lata flap is a good choice. For maximal functional and reconstructive results, a multidisciplinary approach in pressure ulcer treatment has the leading role in the modern concept of wound healing. Surgical treatment should always include radical debridement, ostectomy and well planned defect reconstruction. Conservative treatment should be support to surgical treatment with a focus on patient health care and high hygiene measures. In recent years (2011-2016), the usage of better conservative treatment led to reduction of patient hospital stay and surgical treatment of pressure ulcer. Further 'wound care' nurses training in Croatia can lead the trend towards advanced practice nursing in pressure ulcer prevention and conservative treatment.

Ultrasound-guided bipolar radiofrequency ablation of breast cancer in inoperable patients: a pilot study.

PURPOSE: Radiofrequency ablation (RFA) is a promising minimal invasive modality to treat small breast cancer (BCA). In most studies cancers were surgically excised shortly after RFA. We present six patients inoperable when diagnosed with BCA, and performed RFA instead of surgery. MATERIALS AND METHODS: Ultrasound-guided bipolar RFA was performed under local anesthesia in six women aged 63 - 85 years. They had core-biopsy proven T 1 - 2N0 M0, grade I or II, 1.0 - 2.7 cm sized invasive ductal cancers, with positive estrogen receptor status. Four tumors measured > 2 cm, and three 1.0 - 1.2 cm in diameter. Patients were at high-risk for general anesthesia and surgery because of severely impaired cardiac function, advanced age, or associated diseases (acute myeloid leukaemia (AML), diabetes, hypertension, depression) and/or refused surgery. RESULTS: Six tumors in five patients were completely ablated, without recurrence during follow-up (range: 9 - 49 months). One superficially located cancer was partially ablated; the patient died two months later from myocardial infarction. The Patient with AML and BCA had an infection of the treated breast after 4 months and postponed mastectomy to an AML remission status. There were no signs of malignancy in histopathology; the patient finally died of leukemia 42 months after RFA. The remaining four patients are well, without complications. CONCLUSION: Ultrasound-guided percutaneous RFA under local anesthesia is an effective alternative to surgery for BCA < 3 cm in patients with a high-risk for surgery.

[Surgical treatment of irradiation-induced sarcoma after treatment for breast carcinoma, personal experience: 4 case reports] ]. / Kirursko lijecenje sarkoma induciranih iradijacijom poslije lijecenja karcinoma dojke, nase iskustvo: prikaz cetiriju bolesnica.

In the Department of Plastic Surgery of "Dubrava" University Hospital from 1993 to 1999 four patients were treated for radiation induced sarcoma. All of the patients were formerly operated for breast cancer and irradiated postoperatively. The mean time span between radiotherapy and development of sarcoma was 4.75 years. Four patients were treated with wide excision and immediate reconstruction with local flaps. One of the patients had fibrosarcoma, two patients had lymphangiosarcoma, and one patient had osteosarcoma. Two patients died within two years. Radiation induced sarcomas are therapy resistant, and the review of literature did not show large controlled investigations which would offer the most optimal treatment. Most frequently a rapid progression of the disease is seen.

Reconstruction of upper-extremity peripheral-nerve injuries with ePTFE conduits.

This reported investigation was designed to determine the role of a new synthetic conduit-expanded polytetrafluoroethylene (ePTFE) tube--in clinical repair of median and ulnar nerves in the upper extremities. The main goals of this study were: to determine the effectiveness of the ePTFE conduit in clinical nerve reconstruction; to evaluate the potential of this technique in reconstruction of various nerve gaps (1.5 to 6 cm); and to analyze the results of repair with the ePTFE tube regarding different mechanisms of injury. Forty-three patients were evaluated. They had upper-extremity peripheral-nerve injuries (21 injuries to the median nerve, and 22 ulnar nerve injuries) located at the various levels of the upper extremities. All surgical procedures described in the study were secondary reconstructions, and the average delay from injury to repair was 4.2 months. With regard to the nerve-gap lengths, patients were categorized in two groups. Group 1 (gaps from 1.5 to 4 cm) included 28 patients (17 median nerve injuries and 11 ulnar nerve injuries), and Group 2 (gaps from 4.1 to 6 cm) comprised 15 patients (4 median nerve injuries and 11 ulnar nerve injuries). Results showed that 78.6 percent of patients from Group 1 demonstrated functional motor and sensory recovery, while reconstruction of only 13.3 percent of peripheral nerves from Group 2 resulted in useful reinnervation. According to published results, ePTFE conduit is a reliable and successful surgical procedure for nerve repair in reconstruction of nerve gaps up to 4 cm between the ends of median and ulnar nerves in various levels of the upper extremity. Because of its properties, ePTFE conduit has the advantages of promoting better nerve regeneration, compared to other synthetic tubes, especially in reconstruction of proximal nerve injuries, larger nerve gaps, and in cases with unfavorable mechanisms of nerve injury.

Ulnar nerve reconstruction with an expanded polytetrafluoroethylene conduit.

The ulnar nerve of a 22-year-old woman was reconstructed by expanded polytetrafluoroethylene (ePTFE) conduit, 141 days after nerve transection at the distal forearm level. A 2.9 cm nerve gap was bridged by a corrugated, 3.9 cm long, 6 mm diameter ePTFE tube. At final evaluation 3 years later the patient achieved excellent motor and sensory recovery. Exploration of the tube, at that time, showed macroscopically normal nerve inside the conduit.

[Silicone breast implants and risk of carcinoma]. / Silikonski implantati za dojku i rizik od karcinoma.

Breast reconstruction, i.e. enlargement of the breast by use of silicone implants, has been performed for almost 40 years. Due to its qualities silicone is being widely used in different branches of surgery. New scientific and technological knowledge have resulted in a variety of types of silicone implants (sheet, filling). There is a great interest, but also controversies concerning the development of breast cancer and connective tissue disease in implant bearing patients. There is no evidence on the influence of silicone implants on the breast cancer development. Regardless of the presence of the implant, standard mammography, additional tangential projections, Eklund's maneuver, ultrasonography in addition to a careful clinical examination are sufficient for an adequate follow-up and detection of even minimal changes within the breast tissue.

One-stage reconstruction of war wounds with free osteocutaneous flaps.

Thirty-one patients with traumatic osteocutaneous defects of the extremities sustained during the war in Croatia and Bosnia and Herzegovina were treated at the Institute of Plastic-Reconstructive and Breast Surgery in Zagreb. Injuries were categorised using the Mangled Extremity Syndrome Index (MESI). The average length of bone defect was 5.9 cm (range 4-12 cm). Patients were divided in two groups according to the time they had reconstruction with a free osteocutaneous flap: group 1, within 6 days after injury, and group 2, after more than 6 days. The mean time to reconstruction in group 2 was 5.2 weeks. Average time to solid bone union was 13.3 weeks in group 1 and 16.6 weeks in group 2. Functional outcome was better in group 1 with fewer complications, smaller number of operations and shorter hospital stay. One-stage reconstruction of osteocutaneous defects with free composite flaps provides reliable treatment solution with good functional outcome.

Treatment of upper limb nerve war injuries associated with vascular trauma.

During a 4-year period, in the Departments of Plastic Surgery and Vascular Surgery at the Clinical Hospital Centre in Zagreb, 151 upper limb nerve injuries caused by war weapons were treated using microsurgical procedures, and 119 patients have been assessed. Among them, 44 patients with 58 nerve injuries had associated arterial injuries. It is of great importance that peripheral nerve as well as vessel injuries should be considered in all extremity war wounds. Every effort should be made to perform immediate revascularization of a damaged artery, as this is the best guarantee for long-term arterial patency. Reconstruction with autologous vein has been the method of choice for arterial war injuries. Injured peripheral nerves, at the time of vascular repair, were marked and left for secondary reconstruction. Primary repair of such injuries was contraindicated because it was impossible to determine the exact proximal and distal extent of injury. Functional results were obtained in only 44.8 per cent of cases with concomitant nerve and arterial war injuries, an outcome that could be explained by insufficient vascularization at the site of nerve repair (using both mechanisms of graft revascularization), as well as proximal levels of injury and extent of nerve damage, which resulted in long nerve defects.

[Reconstruction of the cervical esophagus with free autotransplantation of the jejunum--direct monitoring of viability]. / Rekonstrukcija vratnog jednjaka slobodnim autotransplantatom jejunuma--izravno pracenje vitalnosti.

Although free jejunum transfer has become an accepted form of hypopharyngeal reconstruction, an ideal method of monitoring the viability of the graft has not been devised yet. The method of direct visualisation through the incision in the skin above the transferred jejunum has proven very reliable and easy to perform, especially for the nursing staff. This reliable method of monitoring free vascularised jejunum to the neck region has been used in two patients. After two days of direct monitoring, the incision in the skin healed without additional sutures. No failures of the graft occurred, and 12 days later the patients were able to swallow fluids without difficulty. The effectiveness of this technique has surpassed that of all previously published methods.

[Present status and perspectives of plastic surgery in Croatia]. / Sadasnje stanje i perspektive plasticne kirurgije u Hrvatskoj.

Medical treatment in the field of plastic surgery has been known since 5000 B. C. Despite that, it was only since World War I that plastic surgery developed as a new branch of surgery a separate organization. In Croatia, plastic surgery started after World War II. Today Croatia has already the seventh generation of surgeons educated in plastic surgery. The Health Legislation of 1994 recognized plastic surgery as a subspecialty of general surgery. This kind of organization is also known in the world. Education of this type is necessary considering a great need for sophisticated reconstruction procedures in plastic surgery. During the war in Croatia, which started in 1991, a small number of surgeons practising plastic surgery successfully treated a great number of casualties. However, in the post-war period emerged the need for secondary reconstructions in many patients. A new centre for plastic surgery, where surgeons with microsurgical skills who are able to do complicated microsurgical reconstructions would work, should solve this problem.

The management of war wounds to the extremities.

We present our experience in the treatment of war wounds in 174 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. The wounds were divided into four categories depending on the type of injury and the extension of the soft tissue defect which showed the differences in primary excision and reconstruction of wounds. Patients were placed in one of two groups depending on their primary treatment and time of definitive reconstruction. Group A comprised 79 patients who were initially treated by plastic surgeons and whose reconstructive procedure was done within five days. Group B comprised 95 patients who were initially treated in a field hospital and referred later to the plastic surgery unit for definitive reconstruction more than five days after the injury. Sixty-nine (87%) of the patients in group A had only one or two debridements before definitive closure and stayed in hospital 20 days or less. In group B, 59 (62%) of the patients required three or more debridements before definitive closure and remained in hospital more than 21 days (p < 0.001). Proper primary treatment and early reconstruction result in significantly shorter duration of hospital stay and lead to more effective rehabilitation and recovery of the patients. A knowledge in terminal ballistics is important in the understanding of the pathophysiology of war wounds.

War wounds management--early reconstruction of soft tissue defects.

The authors emphasize that the knowledge of terminal ballistics is important for understanding the pathophysiology of war wounds. They present their own experiences in the treatment of war wounds in 504 casualties treated at the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. The locations of soft-tissue defects were: head and neck, 103; trunk, 90; and extremities, 903. War wounds were divided into four main categories with regard to the type of the injury and the extension of soft-tissue defect, thus showing the differences in primary excision and reconstruction of the wounds. About 30% of head and neck injuries were treated by primary or delayed primary reconstruction. All thoraco-abdominal wounds were type I or II, and most of them (53.3%) were reconstructed with split-thickness skin grafts. The greatest number of sophisticated reconstructions were performed on extremity injuries (63 wounds were reconstructed by local flaps, while free flaps were used in 40 cases). The authors emphasize the importance of proper primary treatment, which is the condition for early reconstruction. This results in significantly shorter hospitalization, so that 62% of the patients were cured in 20 days and then discharged to early rehabilitation.

[Surgical management of war injuries involving soft tissue defects]. / Kirurski postupak kod ratne rane s manjkom mekog tkiva.

In this article, the authors emphasize that the knowledge of terminal ballistics is important for understanding of the pathophysiology of war wounds. They present their own experiences in the treatment of war wounds in 126 casualties, treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center, Zagreb. About 96% of the wounded sustained extremity injuries, while head, neck and thoracoabdominal injuries appeared in a significantly smaller number of cases. War wound were divided into four main categories with regard to type of injury and extension of soft-tissue defect, thus showing the differences in primary excision and in reconstruction of the wounds; 78.6% of head and neck injuries were treated by primary or early primary reconstruction (within three to five days after the injuries have been sustained), while 45.4% of thoracoabdominal injuries were treated by a secondary closure. The greatest number of sophisticated reconstructions were used in extremity injuries (15 wound were reconstructed by local flaps, while free flaps were used in 8 cases). The authors emphasize the importance of proper primary treatment which enables an early reconstruction. This results in significantly shorter hospitalization, so that 87.5% of patients were treated within 20 days and then transferred to early rehabilitation.

High-energy war wounds: flap reconstruction.

In this article, we emphasize that knowledge of terminal ballistics is essential for understanding the pathophysiology of war wounds. We present our own experiences in treatment of high-energy war wounds in 75 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. Patients were divided into three groups with regard to the time of definite reconstruction, using local or free microvascular flaps. About 12% of patients underwent flap reconstruction in the acute phase, associated with low complication rate and the shortest hospital stay. Group II was comprised by 18% of the patients and, considering the number of complications, presented the most unfavorable time for reconstruction. Flap reconstruction in the chronic phase resulted in a substantial prolongation of the hospital stay in 82% of patients. Therefore, we advocate proper primary treatment of wounds aimed at early flap closure. This type of management results in a significantly shorter hospitalization and leads to more effective rehabilitation and recovery of patients.

[Microdochectomy with perioperative dye localization of ducts in patients with nipple secretion]. / Mikrodohektomija s perioperativnim bojenjem izvodnih kanala kod sekrecije iz dojke.

A series of 1321 women having a discharge from the nipple were examined at the outpatient clinic. Of seven basic types of discharge: milky, multicolored, purulent, watery, yellow (serous), serosanguineous and bloody, only the last four represent and indication for surgery. Galactography was performed in 55 patients as a necessary element in the surgical plan of management. In 36 women, the operation of microdochectomy was indicated, but only 24 accepted to be subjected to that procedure. The authors describe a new technique of colour mammary ductal localization which identifies the duct from which the discharge is emerging and assures its complete excision. The procedure combines preoperative methylen blue dye injection followed by periareolar incision of the involved duct using a pair of binocular loops for magnification of the nipple. In all tissue specimens, the cause of a pathological discharge was found: 15 (62.5%) cases presented with fibrocystic disease, and in 6 carcinoma was present. This technique provides a safe and effective method of complete excision of the pathologically involved mammary duct with good cosmetic results.

[Developmental and involutional breast disorders]. / Razvojna i involucijska poremecenja dojke.

The majority of benign breast disorders may be classified as developmental and involutive. Mastalgia and breast nodularity represent the greatest groups of these disorders, while epithelial hyperplasia is a complex benign disorder which is most difficult to be evaluated. Sixty women with diagnosis of cyclic mastalgia and 30 with noncyclic breast pain were followed-up. Patients were administered bromocryptine, danazol or a local progestogel. Better treatment results were achieved in cyclic mastalgia than in women with noncyclic mastalgia. One hundred and forty-five biopsies of the benign breast tissue were examined histologically. Nonproliferative forms were found in 66.9% of the women, proliferative without atypia in 29.65%, and proliferative with atypia in 3.45% of the patients. Atypical ductal hyperplasia and atypical lobular hyperplasia increase four-to fivefold the risk for breast cancer. Prophylactic subcutaneous or total mastectomy is not as a rule indicated in atypical epithelial hyperplasia, only regular follow-up is required.

[Transplantation of the peripheral nerves]. / Transplantacija perifernih zivaca.

The development of microsurgery made possible neurorrhapy of even very tiny peripheral nerves. In case of a transsection of a nerve without a defect or with a minor one up to 15 mm, approximation of stumps can be done directly. Larger defects are bridged with autogenous nerve grafts. In order to avoid this, novel technics like cadaveric allogenous grafts or using veins and small tubes of absorbable materials as a guiding rail have been introduced. For purpose of this degenerated muscle grafts are being also applied.