Giant Primary Apocrine Carcinoma of the Frontal Region: Clinical Presentation, Histopathological Features, and Surgical Treatment.

Primary cutaneous apocrine carcinoma (PCAC), a subtype of sweat gland carcinoma, is an extremely rare malignant neoplasm. Distinguishing an apocrine carcinoma from a breast carcinoma metastasis is difficult even for a pathologist. Most arise in regions of high apocrine gland density like the axilla, and rarely on the scalp and eyelid, but they can occur elsewhere on the skin. Primary cutaneous apocrine carcinoma of the scalp is a rare malignancy most often reported in the literature as case reports or small case series. The giant form of primary cutaneous apocrine carcinoma in the frontal region has not been described in the literature, to the best of our knowledge. There are no established protocols for treatment of primary cutaneous apocrine carcinoma. We report a case of a giant primary cutaneous apocrine carcinoma localized in the frontal region. A definitive diagnosis of a primary cutaneous apocrine carcinoma was established by biopsy with microscopic and immunohistochemical analysis. Wide surgical excision and reconstruction with large local transposition flap and split thickness skin grafts for secondary defect were our therapy of choice. Primary cutaneous apocrine carcinoma is a very rare malignancy, and the giant form has not yet been described. Surgical treatment provided the patient with tumor-free status as well as satisfactory aesthetical appearance and quality of life.

Association of vascular endothelial growth factor expression with patohistological parameters of cutaneous melanoma.

BACKGROUND/AIM: Melanoma is the most aggresive malignant tumor of the skin. Contradictory data was published on vascular endothelial growth factor (VGEF) in tumor samples and its role in skin melanoma progression and prognosis. The aim of this study was to investigate the significance of VEGF expression as a prognostic parameter in melanoma. METHODS: The experimental group included 81 patients with primary skin melanomas treated from 2009 to 2013 at the Military Medical Academy, Belgrade. The control group included 20 patients with dysplastic and 20 with benign naevi. Stratification was done according to gender, age, clinical and patological stage, localization, histologic type, Clark's, Breslow, mitotic count, regression and ulceration, tumor infiltrating lymphocytes and metastatic spread.Immunohistochemical staining was performed on skin biopsies using DAKO anti-VEGF antibodies (Ab), LSAB+HRP, DAB and microvawe antigen (Ag) retrieval in DAKO pH 9.0 solution. For statistical data analysis was done with ANOVA, Bonferroni, Mann Whitney and Wilcox on test. RESULTS: The mean intensity of VEGF staining was statistically significantly higher in melanomas than in benign or dysplastic naevi. Furthermore, the highest recorded values were in Ia and IV clinical stages. The majority of melanomas with high intensity of VEGF staining were in pT1a pathological stage. Melanomas with the highest mitotic count (> 6) had a significantly higher intensity of VEGF staining than those with < 2 mitoses. The higest intensity of staining was in melanomas without significant lymphocytic infiltrate and the lowest was in those with brisk lymphocytic infiltrate, thus a statistical difference was siginifant. The mean intensity of VEGF staining was highest in melanomas with lymphovascular invasion. There was no statistically significant difference between VEGF and any other parameter. CONCLUSION: VEGF in primary skin melanomas plays an important role in tumor progression and is linked to the absence if tumor infiltrating lymphocytes and the presence of lymphovascular invasion. More detailed studies have to be done on VEGF prognostic value in melanoma on a larger number of patients.

Lymphoscintigraphy and sentinel lymph node biopsy, in cutaneous melanoma staging and treatment decisions.

OBJECTIVE: Sentinel lymph node biopsy (SLNB) is a widely accepted method in the management of clinically localized cutaneous melanomas. The aim of this study was to report the results on patients scheduled for preoperative lymphoscintigraphy and SLNB for staging and further treatment planning. SUBJECTS AND METHODS: Two hundred and one patients (115 male and 86 female, median age 57 years, range 9-81) with cutaneous melanoma having undergone SLB at Military Medical Academy between November 2010 and October 2014, were recruited for retrospective study. Dual labeling method (Tc-99m Nanocolloid (blue dye) was used. In order to delineate the relation between patients' tumors and scintigraphic characteristics with positive SLN findings, we examined all variables by univariate logistic regression with odd ratios representing the size effect. RESULTS: The overall identification rate of SLN was 98.5%. One or more positive SLN were seen in 47 (23.4%) of the patients. Drainage to one regional basin was noticed in 176 (88%) and multiple drainage regions, up to three, was noticed in 24 patients (12%). Transit lymph nodes were detected in 20 patients (10%). The characteristics that were assotiated significatly with sentinel lymph node metastases were Breslow thickness, nodular melanoma histological subtype and acral localization. CONCLUSION: Besides the well established primary tumor thickness being a predictor of SLN malignancy, we observed: acral body site location and nodular melanoma histological subtype to be significant independent factors in increasing the risk for regional metastases. Our results suport the clinical usefulness of SLNB within a multidisciplinary approach (dermatooncology, plastic/head and neck surgery, pathology, nuclear medicine), as a reliable method in staging and for treatment planning in melanoma patients.

Clinicopathological characteristics, diagnosis and treatment of melanoma in Serbia--the Melanoma Focus Study.

BACKGROUND/AIM: Treatment options for metastatic melanoma in Serbia are limited due to the lack of newly approved biologic agents and the lack of clinical studies. Also, there is a paucity of data regarding the treatment approaches in different tertiary centers and efficacy of available chemotherapy protocols. The aim of this study was to obtain more detailed data about treatment protocols in Serbia based on structured survey in tertiary oncology centers. METHODS: Data about the melanoma patients treated in 2011 were analyzed from hospital databases in 6 referent oncology centers in Serbia, based on the structured survey, with the focus on metastatic melanoma patients (unresectable stage IIIC and IV). RESULTS: A total of 986 (79-315 in different centers) patients were treated, with 320 (32.45%) newly diagnosed patients. There were 317 patients in stage IIIC/IV, 77/317 aged < 50 years. At the time of diagnosis 47.3% of patients were < 60 years of age (24.2% < 40 years, 23% 50-59 years, 52.6% > 60 years). At initial diagnosis 12.5% of patients were in stage III and 4.5% in stage IV. The most common type was superficial spreading melanoma (50-660), followed by nodular melanoma (23.5-50%). Apart from the regional and distant lymph node metastases, the most frequent organs involved in stage IV disease were distant skin and soft tissues (12-55%), lungs (19-55.5%), liver (10-60%), and bones (3-10%). The first line therapy in stage IV metastatic melanoma was dacarbazine (DTIC) dimethyl-triazenoimidozole-carboxamide in 61-93% of the patients, while the second line varied between the centers. Disease control (complete response + partial response + stable disease) was achieved in 25.7% of the patients treated with the first line chemotherapy and 23.1% of the patients treated with the second line therapy, but the duration of response was short, in first-line therapy 6.66 +/- 3.36 months (median 6.75 months). More than 90% of patients were treated outside the clinical trials. CONCLUSION: Based on this survey, there is a large unmet need for the new treatment options for metastatic melanoma in Serbia. The development of national guidelines, and greater involvement in international clinical studies could lead to widening of treatment options for this chemotherapy resistant disease.

Interferon alpha-induced reduction in the values of myeloid-derived suppressor cells in melanoma patients.

BACKGROUND/AIM: Interaction between tumor cells and host's immunoregulatory cells in creation of microenvironment that supports tumor progression is the focus of numerous investigations in recent years. Myeloid-derived suppressor cells (MIDSCs) are heterogeneous population of immature dendritic cells, macrophages and granulocytes. In cancer patients, these cells accumulate in tumor microenvironment, tumor-draining lymph nodes, peripheral blood and the liver and their numbers correlate with the stage of the disease and the metastatic disease. The aim of the study was to investigate the effect of interferon alpha on MDSCs percentage in peripheral blood of melanoma patients. METHODS: The interferon treated melanoma patients were given subcutaneously interferon alpha, in optimal dose, for a period of at least 6 months before the analysis. Blood samples were collected from the melanoma patients (n=91) and the age/sex matched healthy controls (n=8). The following anti-human monoclonal antibodies were used for immunostaining: anti-CD15-FITC, anti-CD33-PE, anti-CD45-ECD, anti-HLA-DR PE/Cy5, anti-CD14-FITC, anti-CD16-PE and anti-CD11b-PE. RESULTS: Comparison of myeloid- derived suppressor cells values in the stage 2 melanoma patients with and without interferon alpha therapy did not show a significant difference. When we compared the MDSCs values in the patients within stage 3 melanoma, we found a significant difference in granulocytic subset values between the interferon alpha-treated and the untreated group. Comparison of values of all suppressor cells populations between the interferon alpha-treated patients and healthy controls showed a significant increase in suppressor cells percentage in the melanoma patients. The granulocytic and total MDSCs values were significantly lower in the interferon alpha treated melanoma patients with progression in comparison with untreated patients with stable disease. CONCLUSION: We confirmed that interferon alpha effect in stage 3 melanoma patients was reduction in MDSCs percentage. We also found an unexpected bounce back of these suppressor cells levels, many months after the discontinuation of interferon alpha therapy.

Melanoma risk is associated with vitamin D receptor gene polymorphisms.

Previous studies have reported that vitamin D receptor (VDR) gene polymorphisms are associated with the occurrence of various cancers, including melanoma. The aim of the current study was to investigate the association of VDR gene polymorphisms with melanoma risk, clinicopathological characteristics, and vitamin D levels. The study group included 117 patients (84 patients with superficial spreading melanoma and 33 patients with nodular melanoma). The control group included 122 sex-matched and age-matched healthy-blood donors of the same ethnicity. VDR gene polymorphisms FokI, EcoRV, TaqI, and ApaI were genotyped by real-time PCR. In 60 patients, the total 25-hydroxyvitamin D levels were evaluated in serum samples by direct chemiluminescence. Associations among parameters were considered to be significant if the P value was less than 0.05. Significant differences in the frequencies of VDR genotypes were observed between cases and the control group for FokI and TaqI polymorphisms (P<0.0001; P=0.005, respectively). Heterozygous Ff as well as mutant FF genotypes of the FokI polymorphism were associated with increased melanoma risk compared with the wild-type form [odds ratio (OR)=3.035, P=0.003; OR=9.276, P<0.0001, respectively]. A significantly increased melanoma risk was observed for the heterozygous Tt (OR=2.302, P=0.011) and the mutated variant tt (OR=3.697, P=0.003) of the TaqI polymorphism in comparison with the wild-type genotype. None of the polymorphisms studied was associated with clinicopathological characteristics and vitamin D serum level. Our results suggest that FokI and TaqI polymorphisms in the VDR gene may be considered as potential biomarkers for melanoma susceptibility. Low vitamin D levels in melanoma patients indicate the need for vitamin D supplementation.

[Effect of mechanical pressure-controled ventilation in patients with disturbed respiratory function during laparoscopic cholecystectomy].

BACKGROUND/AIM: Laparoscopic cholecystectomy is considered to be the gold standard for laparoscopic surgical procedures. In ASA III patients with concomitant respiratory diseases, however, creation of pneumoperitoneum and the position of patients during surgery exert additional negative effect on intraoperative respiratory function, thus making a higher challenge for the anesthesiologist than for the surgeon. The aim of this study was to compare the effect of intermittent positive pressure ventilation (IPPV) and pressure controlled ventilation (PCV) during general anesthesia on respiratory function in ASA III patients submitted to laparoscopic cholecystectomy. METHODS: The study included 60 patients randomized into two groups depending on the mode of ventilation: IPPV or PCV. Respiratory volume (VT), peak inspiratory pressure (PIP), compliance (C), end-tidal CO2 pressure (PETCO2), oxygen saturation (SpO2), partial pressures of O2, CO2 (PaO2 and PaCO2) and pH of arterial blood were recorded within four time intervals. RESULTS: There were no statistically significant differences in VT, SpO2, PaO2, PaCO2 and pH values neither within nor between the two groups. In time interval t1 there were no statistically significant differences in PIP, C, PETCO2 values between the IPPV and the PCV group. But, in the next three time intervals there was a difference in PIP, C, and PETCO2 values between the two groups which ranged from statistically significant to highly significant; PIP was lower, C and PETCO2 were higher in the PCV group. CONCLUSION: Pressure controlled ventilation better maintains stability regarding intraoperative ventilatory parameters in ASA III patients with concomitant respiratory diseases during laparoscopic cholecystectomy.

Surgical anatomy and histology of the levator palpebrae superioris muscle for blepharoptosis correction.

BACKGROUND/AIM: The detailed knowledge of the architecture of the upper eyelid is very important in numerous upper eyelid corrective surgeries. The article deals with the detailed anatomy of the major components of the upper lid, which are commonly seen in surgical practice. METHODS: This study was conducted on 19 human cadavers (12 adults and 7 infants) without pathologic changes in the orbital region and eyelids. Anatomic microdissection of the contents of the orbita was performed bilaterally on 12 orbits from 6 unfixed cadavers (3 male and 3 female). Micromorphologic investigations of the orbital tissue were performed on 8 en bloc excised and formalin-fixed orbits of infant cadavers. Specimens were fixed according to the Duvernoy method. An intra-arterial injection of 5% mixture of melt formalin and black ink was administered into the carotid arterial system. Using routine fixation, decalcination, dehydration, illumination, impregnation and molding procedures in paraplast, specimens were prepared for cross-sections. RESULTS: The measurement of the muscle length and diameter in situ in 6 nonfixed cadavers (12 orbits) showed an average length of the levator palpbrae superioris (LPS) muscle body of the 42.0 +/- 1.41 mm on the right, and 40.3 +/- 1.63 mm on the left side. In all the cases, the LPS had blood supply from 4 different arterial systems: the lacrimal, supratrochlear, and supraorbital artery and muscle branches of the ophthalmic artery. The LPS muscle in all the specimens was supplied by the superior medial branch of the oculomotor nerve. The connective tissue associated with the LPS muscle contains two transverse ligaments: the superior (Whitnall's) and intermuscular transverse ligaments (ITL). The orbital septum in all the specimens originated from the arcus marginalis of the frontal bone, and consisted of two layers--the superficial and the inner layer. In addition, a detailed histological analysis revealed that the upper eyelid's crease was formed by the conjoined fascia including the fascia of the orbicularis muscle, the superficial layer of the orbital septum, and the aponeurosis of the LPS muscle, as well as the pretarsal fascia. CONCLUSION: The conducted study provided a valuable morphological basis for biomechanical and clinical considerations regarding blepharoptosis surgery.

Congenital upper eyelid coloboma with ipsilateral eyebrow hypoplasia.

INTRODUCTION: Coloboma is a Greek word, which describes the defect of all layers of the organ, and it can be congenital or as the result of an injury, operation, or some disease. Congenital upper eyelid coloboma is a rare anomaly, with the unknown incidence. The size of the defect is different, but it always involves all layers of the eyelid. This malformation is more frequent at the upper eyelid, and unilaterally, at the junction of the medial two thirds. Sometimes, it can also involve the eye, and may be a component of many syndromes (Goldenhar, Fraser, Manitoba, CHARGE, Cat eye). CASE REPORT: We are describing the case of the upper eyelid coloboma with the rare eyebrow anomaly at the three- month old girl, and the result of reconstruction. The baby was treated conservatively with lubricants and overnight patching. Pentagonal excision of the defect was performed in general anesthesia. Three layers of the eyelid were prepared: the skin, muscle and tarsoconjunctival layer. Because of orbicularis muscle malposition, reinsertion and reposition of the muscle fibres were performed. Then, lateral canthotomy was made and the suture of three layers of the eyelid. Catgut suture 7-0 was used for the conjunctiva and muscle. Nylon 6-0 was used for skin suture. Z-plasty was done on the upper part of the pentagonal excision in order to reduce skin tension at the suture line. The operation lasted about 60 minutes and the hospitalization three days. The occlusive dressing was applied for two days. The stitches were removed after seven days. The postoperative swelling of the upper and lower eyelid disappeared in five days. There were no complications in the postoperative period. CONCLUSION: The main principle of the treatment of eyelid coloboma is surgical reconstruction of all layers of the eyelid, in optimal period, using different surgical methods, which depends on the size of the defect. An early diagnosis is of the greatest importance, as well as the treatment of associated anomalies. Complications of the upper eyelid coloboma depend on the size of the defect, presence of the eye anomalies and the method of reconstruction.

Melanoma in South-East Europe: epidemiological data from the central cancer registry and clinicopathological characteristics from the hospital-based registry in Serbia.

BACKGROUND: Melanoma in South-East Europe shows varying incidence from 1.7 per 100,000 in Albania to 14.5 per 100,000 in Slovenia, but more detailed data from this region are scarce. In this study, we report epidemiological and clinicopathological characteristics of melanoma in central Serbia. MATERIALS AND METHODS: Epidemiological data were retrieved from the Cancer Registry of Central Serbia and clinicopathological data from the hospital-based registry. RESULTS: The ASR(W) incidence rate of melanoma was 4.2/100,000 (males) and 3.9/100,000 (females), and ASR(W) mortality rates were 1.9/100,000 (males) and 1.4/100,000 (females), with recorded rising trends in both of them. Data from the hospital-based registry revealed a total of 266 patients treated from 2005 to 2010, with the median age at diagnosis of 57 (13-86) years. The most frequent histopathological subtype was superficial spreading melanoma (SSM; 63.53%), and ulceration was present in 40.6% of primary tumors. Median Breslow thickness was 3 mm (0.1-25 mm). Primary tumors with thickness of more than 4 mm were found in 31.95% of patients, and in this group statistically significant difference was found for younger age in patients with SSM (55 years vs. 61 years, P = 0.04). CONCLUSION: Low incidence rates in central Serbia and probably other countries of South-East Europe are accompanied by a large percentage of thick tumors and a significant proportion of younger patients with thick tumors. This points to the urgent need for more effective primary and secondary prevention of melanoma in these countries.

[Hemodynamic stability in total intravenous propofol anesthesia with midazolam coinduction versus general balanced anaesthesia in laparoscopic cholecystectomy].

BACKGROUND/AIM: Laparoscopic cholecystectomy can be a greater challenge for anesthesiologist than for surgeon if the patient is ASA III with concomitant cardiovascular diseases. The aim of our study was to compare the effect of total intravenous anesthesia (TIVA--propofol with midazolam) and general balanced anesthesia (GBA--midazolam, thiopenton, nitrous oxide and 02) on hemodynamic stability in the ASA III patients who underwent laparoscopic cholecystectomy. METHODS: In our study, 60 patients were randomized into two groups depending on whether they received TIVA or GBA. Heart rate, systolic, diastolic and mean arterial pressure were monitored continuously and recorded in five time intervals. RESULTS: Statistical analysis showed that TIVA with propofol provides better hemodynamic stability (less than 10% deviation from basal values for each measured parameter) then GBA group (p < 0.01). CONCLUSION: Total intravenous anesthesia with propofol provides better hemodynamic stability for ASA III patients with concomitant cardiovascular diseases then GBA.

Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

Skin vascularisation field by the ascending branch of the peroneal artery ramus perforans.

BACKGROUND/AIM: Soft tissue defects in the distal third of the lower leg are persistent and constitute a major problem in the reconstructive surgery. This study presents an analysis of the anatomical vascularization filed of ascending branch of the peroneal artery ramus perforans (PARS). The aim of this study was to assess reliability of the distal flap on the antero-lateral aspect of a lower leg distal third. METHODS: Direct gentiana violet injection into the interosseal perforator of ten fresh cadaveric lower legs with subsequent corrosion acrylic preparation was performed to reveal vascularization filed of the ascending branch of the PARP. Height, length, diameter and communication of perforating branch and its subsequent smaller ascending and descending branches were determined. The CAMIA software was used. RESULTS: Our results show that the PARP is always present. Its origin from the peroneal artery is at the medial height of 66 mm when measured from the inferior border of the lateral malleolus. Medium length of ramus perforans is 51.7mm. After transition through the interosseous membrane, ramus perforans divides into ascending and descending branches. The diameter proximal to the level of bifurcation is 1.37 mm (variation 1.0-1.8 mm), and the diameter of the ascending branch distal to the level of bifurcation is 1 mm. Using CAMIA software, the medium length, width and area of the vascularization filed labeled with gentian violet were calculated to be 164 mm (variation 125-210 mm), 66 mm (57-77 mm), and 10,305 mm2 (6,385 mm2-14,341 mm2), respectively. CONCLUSION: Our results support the use of fasciocutaneous distal flap, vascularized by the ascending branch of the PARP for reconstruction of soft tissue defects in the distal third of the lower limb, malleolar regions and dorsum.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries.

BACKGROUND/AIM: There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. METHODS: We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). RESULTS: During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, "pubertal" (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, "pubertal" asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achive satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. CONCLUSION: Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

Denonvilliers' advancement flap in congenital alar rim defects correction.

BACKGROUND: Alar rim defects are mostly acquired, resulting from burns, traumas or tumor excision. Sometimes they can accompany craniofacial clefts. However, isolated congenital alar defects are extremely rare. CASE REPORT: We presented two cases of congenital isolated alar cleft. The defect was closed by the use of an advancement flap, the technique described by Denonvilliers. We achieved both symmetry and appropriate thickness of the nostrils. Skin color and texture of the alar rim were excellent, with scars not excessively visible. CONCLUSION: Denonvilliers' z-plasty technique by using advancement flap provides both functionally and aesthetically satisfying outcome in patients with congenital alar rim defects.

[Microvascular free flaps and care of war injuries with tissue defects]. / Mikrovaskularni slobodni reznjevi u zbrinjavanju ratnih rana sa defektima tkiva.

BACKGROUND: War wounds caused by modern infantry weapons or explosive devices are very often associated with the defects of soft and bone tissue. According to their structure, tissue defects can be simple or complex. In accordance with war surgical doctrine, at the Clinic for Plastic Surgery and Burns of the Military Medical Academy, free flaps were used in the treatment of 108 patients with large tissue defects. With the aim of closing war wounds, covering deep structures, or making the preconditions for reconstruction of deep structures, free flaps were applied in primary, delayed, or secondary term. The main criteria for using free flaps were general condition of the wounded, extent, location, and structure of tissue defects. The aim was also to point out the advantages and disadvantages of the application of free flaps in the treatment of war wounds. METHODS: One hundred and eleven microvascular free flaps were applied, both simple and complex, for closing the war wounds with extensive tissue defects. The main criteria for the application of free flaps were: general condition of the wounded, size, localization, and structure of tissue defects. For the extensive defects of the tissue, as well as for severely contaminated wounds latissimus dorsi free flaps were used. For tissue defects of distal parts of the lower extremities, scapular free flaps were preferred. While using free tissue transfer for recompensation of bone defects, free vascularized fibular grafts were applied, and in skin and bone defects complex free osteoseptocutaneous fibular, free osteoseptocutaneous radial forearm, and free skin-bone scapular flaps were used. RESULTS: After free flap transfer 16 (14.4%) revisions were performed, and after 8 unsuccessful revisions another free flaps were utilized in 3 (37.5%) patients, and cross leg flaps in 5 (62.5%) patients. CONCLUSION: The treatment of war wounds with large tissue defects by the application of free microvascular flaps provided shorter wound-closing period, earlier beginning of physical therapy, as well as the treatment of great number of patients with the extensive tissue defects in the conditions of massive influx of the wounded.