Ivica Ducic_ MD_ PhD by niusheng11


									      Ivica Ducic, MD, PhD
     Associate Professor - Plastic Surgery
      Georgetown University Hospital

- 3800 Reservoir Rd, NW, Washington, DC 20007
- 6845 Elm Street, Suite 603, McLean, VA 22101
  Tel: (202) 444-8929      Fax: (202) 444-8915

Dear Patient,

     I want to welcome you to our office. By way of introduction, outlined here for you is my brief
educational background, special interests and a preface to some special procedures. Please take a moment
to read it; I hope it may be beneficial to you or someone you know.

    I am a Board Certified Plastic Surgeon who enjoys many aspects of aesthetic and reconstructive
plastic surgery. I received my medical degree in 1991 from University of Zagreb School of Medicine
(Croatia, Europe), and a Ph.D. degree in 1995 in the field of medical sciences and pharmacology. Upon
completing post-graduate training in Plastic Surgery at Georgetown University Hospital in 2002, I entered
a one-year peripheral nerve surgery fellowship at the Institute for Peripheral Nerve Surgery. I then joined
the full time faculty practice at Georgetown University Hospital Department of Plastic Surgery in August
2003. Here I currently hold the rank of an Associate Professor and am a chief of peripheral nerve surgery.

    My background allows me to customize each patient's treatment plan and thus optimize functional
and aesthetic result. Armed with a 5-year basic science research experience, I continue to be very
involved with research, as the extensive list of scientific publications and presentations confirm, thus
staying on the cutting edge of new advances in medical and surgical treatment for my patients. At least
several times each year I attend plastic surgery national and international meetings, teaching about my
experience and enriching my own knowledge with new advances in medicine. I am a member of several
major plastic surgery societies and have been featured in number of media reports. All of the above
confirm that the safety and quality of the patient’s care is the central principle of my practice.
  Randomly listed Dr. D ucic's special interests include three
                          catego ries:

Peripheral Nerve Surgery For:

     Chronic Headache (Occipital, Frontal or Temporal Neuralgia)
     Upper & Lower Extremity Neuropathies: Carpal, Cubital, Tarsal Tunnel
     Diabetic Symptomatic Neuropathy (Extremity Numbness and/or Pain)
     Chronic Pain Following Surgery or Trauma (Groin, Knee, Trunk, etc)
     Amputation Stump Pain, Foot Drop, Meralgia Paresthetica
     Peripheral Nerve Tumors, Thoracic Outlet Syndrome
     Acute Nerve Injury Following Surgery or Trauma

Cosmetic Surgery:

     Abdominoplasty (Tummy Tuck)
     Breast: Augmentation, Reduction or Lift
     Blepharoplasty (Eyelid Surgery)
     Liposuction and Body Contouring
     Face Lift; Brow Lift
     Botox

Reconstructive Surgery For:

     Complex Wounds and Breast Reconstruction
     Moles, Skin Cancer and Scar Revisions
     Microsurgery (Microvascular Tissue Transfer)
 Peripheral Nerve Surgery:
    Many patients have chronic neuropathy or pain that is resistant to numerous treatment regimens and
travel across the country for relief. I am focused on treating the anatomic and pathophysiologic cause of
symptomatic neuropathy rather then focusing on the treatment of symptoms itself. When teaching, I often
try to pass this kind of thinking onto students and residents because one first needs to understand the
cause of the problem prior to applying different treatment options, otherwise treatment failure is a likely
outcome. It is amazing to see how often this is overlooked. In order to meet this goal, I have been
working to design a number of treatment algorithms specific to the type of nerve damage or pain source.
Therefore, many patients come here for the clinical skills and surgical expertise in peripheral nerve
surgery we offer. Beside a national recognition for this work, it is my special privilege to fulfill the trust
of my patients with most innovative, safe and appropriate surgical treatments.

     Diagnostic Work-up: Although some radiological and most electrophysiological studies can point to
the possible cause of the malfunctioning peripheral nerve, none are absolutely specific for a certain nerve
problem. Often these tests can be normal or “indeterminate” despite the clear presence of pain,
paresthesias, or muscle weakness. For that reason, diagnostic studies are ordered judiciously, while
clinical judgment based on patient’s presentation, complaints, and targeted physical exam are among the
most important factors in making the diagnosis and planning peripheral nerve surgical treatment. Instead
of conventional nerve conduction studies that some might not be able to tolerate due to pain, in selected
patients, I am using a Pressure Specified Sensory Device. This is a non-painful, non-invasive and highly
sensitive test for an objective detection of neuropathy. When teaching, I am also trying to stress the
importance of understanding anatomical variations of nerves possibly involved in traumatic or surgical
field. This can greatly help establish the proper diagnosis and thus facilitate right treatment. Occasionally,
in selected cases, diagnostic work-up is supplemented by nerve blocks (injection of numbing medication
temporarily blocking nerve function) to further define the nerve involved in generating pain. Furthermore,
when lecturing, in order to ensure an optimal outcome I often emphasize the importance that the treating
physician should be a peripheral nerve surgeon, experienced in dealing with given nerve problems, rather
then incidentally encountering complex peripheral nerve problems.
    Peripheral Neuropathy: Patients experiencing any combination of numbness, burning sensation,
pain or muscle weakness have a peripheral neuropathy. A primary care physician or a specialist should
order work-up that would help determine its cause and exclude other non-peripheral nerve related
conditions. Please note that patients who had previous brain or spine surgery are poor candidates for
peripheral nerve surgery since the damage to the nerve is central rather then peripheral.
In addition to surgery or trauma, other common reasons for neuropathy are diabetes, hypothyroidism,
certain autoimmune conditions, vitamin deficiencies, and certain drugs (chemotherapy, lipid lowering
medications and some anti-viral drugs). It is very important that treatment for these conditions is
undertaken, as your doctor prescribed it. I find that the patients who, despite optimal medical treatment
for their condition are continuing to experience the above mentioned signs/symptoms of symptomatic
peripheral neuropathy are considered appropriate surgical candidates. Upon referral, I would determine if
any additional work-up is needed and would verify if, when and what type of the intervention is required.
Most common examples are:
- Carpal tunnel (numbness/paresthesia - first three fingers of the hand - median nerve compression @ wrist)
- Cubital tunnel (numbness/paresthesia - 4th & 5th fingers or hand weakness - ulnar nerve compression @ elbow)
- Radial tunnel (forearm pain with weakness in hand dorsiflexion or finger extension - radial nerve compression)
- Wartenberg’s disease (numbness/paresthesia – dorsum of hand/fingers - radial sensory nerve compression)
- Tarsal tunnel (bottom of the foot neuropathy due to tibial and inner ankle nerve compressions)
- Peroneal nerve compression (top of the foot neuropathy or foot drop, with or without knee trauma)
- Meralgia paresthetica (numbness, pain or burning sensation along the antero-lateral thigh, due to
  compression of lateral femoral cutaneous nerve @ anterior superior iliac spine and inguinal ligament)
- Thoracic outlet syndrome (compression of brachial plexus affecting arm circulation upon arm elevation or
  causing numbness, pain or paresthesias of upper extremity/hand due to cervical rib or stretched plexus nerves)
     It is very important that treatment, if and when indicated is done in a timely manner, as prolonged
‘observation’ can lead to irreversible nerve damage. After this occurs, no surgery will be helpful. Most,
if not all of the above treatments are done on an outpatient basis. It takes one to two hours to perform the
surgery where nerves are decompressed (neurolysed) within a compressive anatomic compartment.
Recovery varies but it usually takes about two-three weeks.

    Acute or Chronic Nerve Damage Following Surgery or Trauma: Any trauma or surgery can result
in acute or ultimately chronic nerve injury or pain (pain persistent beyond normal recovery time for a
given surgery). Treatment approach differs depending on which of the two types of the patient you are.
Patients with an acute nerve injury noted right after surgery or trauma (loss of sensation and/or muscle
function), in order to optimize the outcome, should be evaluated soon (within three-six weeks) from the
event. I could then advise them about proper treatment timing and options. The other group of patients is
somewhat more common, and includes patients whose pain/paresthesia persisted way beyond expected
recovery period following a surgery or had started number of months after the trauma/surgery. They
would benefit from evaluation somewhere between three to six months following the event/surgery. If
despite conservative care, pain medications and/or physical therapy (when applied),
pain/numbness/paresthesia/muscle weakness still persist, indications for treatment with peripheral nerve
surgery are established. Some of the examples include:
- surgical treatment of groin/testicular/vulvar pain after hernia repair or gynecologic/obstetric surgery
- antero-lateral thigh pain/burning/numbness (meralgia paresthetica) following hip or groin surgery
- amputation stump pain (upper or lower extremity amputee stump pain)
- knee pain following knee surgery (after knee scope or total knee replacement, etc)
- foot, leg or upper extremity pain following various surgical treatments, trauma or burns
- trunk or breast pain following various reconstructive breast, thoracic or cosmetic procedures
- headache following various previous surgical treatments or trauma
    The treatment for any of the above conditions would include excision of damaged nerve (neuroma)
and implantation of proximal stump of nerve to muscle (to prevent neuroma recurrence). Some patients
who have a high (proximal) damage of a main nerve might require reconstruction of that nerve with nerve
graft or conduit. Similar reconstruction might be needed following excision of a peripheral nerve tumor.
Depending on the type of the tumor, reconstruction might be limited to a portion (facsicle) of the nerve
rather then the entire nerve diameter. Once reconstructed, the nerve under optimal circumstances recovers
approximately 0.5 to 1 mm/day, so response to surgery might be a delayed functional recovery.

     Chronic (Migraine) Headaches / Occipital Neuralgia: I actively treat patients with chronic
headaches, with outpatient surgical procedures that can help many sufferers from frontal, temporal or
occipital neuralgia related headaches. With some exceptions, many of these patients who have suffered
from long lasting and disabling headaches have experienced complete cure following surgery, while some
have had partial but significant relief. Some are unfortunately found not to be optimal surgical candidates.
It is important to understand that there are patients with a true migraine, patients with a true neuralgia
related headache and those with overlapping symptoms of both. Therefore, it is also important that these
patients, prior to being seen by me, have had a proper diagnosis/work-up, and are involved in an
appropriate medical treatment by a neurologist or similar specialist experienced in headache treatment.
This will ensure that other possible reasons for headaches are excluded and that a patient has also had
nerve blocks or alternatively Botox to confirm the involvement of occipital (greater>lesser) nerves or
supraorbital/trochlear and/or zygomatico-temporal nerves as generators for occipital or fronto-temporal
neuralgia related chronic headaches/migraines, respectively. Patients who continue with
headaches/migraines despite optimal medical care provided by an experienced center/provider, and who
have tenderness over the involved nerves with positive effect (even for few days) of nerve blocks or
Botox are therefore optimal candidates for evaluation for surgical treatment.
                                          Cosmetic Surgery:
    The number of available cosmetic procedures makes it difficult for patients to objectively choose
what would be the most appropriate procedure or set of procedures to improve one’s appearance. On the
other hand, adding a bit more complexity to this issue, many physicians are financially stimulated to
‘suggest’ more procedures than one actually needs or had initially asked for. Combined, this is a platform
for potential problems and less then optimal outcome. It is my personal belief that the patient
herself/himself is the one that should be setting the criteria about what improvements or type of
rejuvenation might be optimal, granted they are safe and appropriate by plastic surgery criteria too.
Listed below are some of the most common cosmetic procedures I perform:
- Abdominoplasty (Tummy Tuck): Removal of excess loose abdominal skin and fat. The resulting scar
is hidden in the suprapubic crease, although it extends between anterior hip bones. Most of these are
planed so that the final scar is within underwear lines, granted that individual’s body build allows it.
Surgery requires overnight stay in the hospital and the use of surgical drains for about 7-10 days.
Recovery varies on the extent of tissue removed, the amount of plication of abdominal wall, and body
habitus, usually taking about 2-3 weeks.
- Breast Augmentation, Reduction or Lift: Depending on individual’s body build and breast cup/size
either breast enlargement, reduction of lift are applied. Breast enlargement is done based on individual’s
preferences, granted it appropriately suits the chest size. It is done either by saline or silicone implants,
whichever patient’s preference may be. A small scar will be located most often along inframammary fold
(most preferred by patients) or alternatively around lower pole of areola. Recovery is fast, with return to
work within several days, depending on the type of the job. Breast reduction includes removal of excess
breast tissue and skin, often responsible for neck or shoulder pain, and interttrigo along the inframammary
fold. Scars are located around areola, extending vertically towards and along inframammary fold. In most
cases surgery requires an overnight stay and use of drains for about 4-7 days. Recovery can be expected
within 7-14 days. Breast lift, although always done with breast reduction, when done as the only
procedure, is for breasts whose nipple and areola have descended towards lowest pole of the breast. The
nipple/areola is then repositioned to its approximate original position, with scars only around areola or
expected to be similar to those for breast reduction. Recovery takes about a week.
- Blepharoplasty (Eyelid Surgery): Upper eyelid surgery is done for excess skin of the eyelid
(sometimes fat too) and results in a scar hidden in the eyelid crease. Lower eyelid surgery, often done for
excessive, bulging fat is usually done from inside the eyelid, resulting in no visible scar. When the
eyebrow (especially the lateral part) appears lower than the orbital rim (bone), a brow lift can be
combined with eyelid surgery to enhance the youthful periorbital appearance. Sutures are removed a week
from surgery; recovery is about a week.
- Liposuction and Body Contouring: Liposuction is a liposculpturing of the body using suction
lipectomy. The ratio between excess fat vs. skin and an appropriate amount of fat to be removed are rather
important issues to be considered both by plastic surgeon and the patient when aiming for an optimal, safe
outcome. Surgery is done via several small ports, leaving small scars, usually hidden in creases whenever
possible. Recovery varies, often taking about a week or two prior to resuming pre-op work activities.
- Facial Rejuvenation (Face Lift / Neck Lift): Aging contributes to descent of all tissues, changing the
way we look. As we age we develop loose and wrinkled skin, resulting in an older appearance.
Correction requires repositioning of soft tissues and removal of excess skin, mostly in the facial and neck
areas. Incisions are hidden and minimally visible, depending on the hair style and gender of the patient.
Surgery is usually done as an outpatient procedure. Sutures are removed a week from surgery; recovery
takes about two weeks (return to work and attending social events can be planned two-three weeks after
- Botox: Correction of fine wrinkled skin resulting from an overactive muscle function can be neutralized
with this technique. Many find it a good alternative to certain surgical procedures, especially when aging
signs are present but insufficient to have surgery. Injections might need to be repeated 4-6 months later.
                                      Reconstructive Surgery:

    Although reconstructive problems can be the result of a congenital deformity, far more commonly
they are associated with acquired conditions like, trauma, acute or chronic medical conditions, tumors and
previous adjuvant or surgical treatments. Regardless of the cause, a soft tissue or composite defect will
need a functional and aesthetically appropriate reconstructive surgery. In order to accomplish this goal, as
a common rule, a tissue defect is reconstructed with tissues of a similar texture/type, recruited locally or
from different area of the body. Reconstructive plastic surgery, performed in any part of the body, can be
done in several different ways, depending on the nature of the problem/condition causing the acquired
deformity or a wound. Since terminology might be confusing, listed are common reconstructive options:
- dressings: wide variety available; use based on number of variables, patient and wound site specific
- debridment: removal of infected or non-viable tissues; combined with dressings and antibiotic therapy
- primary wound closure: immediate, primary wound closure; used whenever possible
- delayed/secondary wound closure: if initial wound conditions do not permit immediate closure, delayed
  direct wound closure is done on a later date; combined with dressings and antibiotic therapy
- healing by secondary intention: wounds left to heal on their own; used with dressing changes
- local tissue rearrangement: reconstruction by recruitment of local tissues, enabling defect closure
- skin grafts: split or full thickness, used for wide but superficial wounds when local tissues are insufficient
- local flaps: local tissues used for more complex wounds requiring coverage of important structures
- free flaps: distant tissues used for the most complex wounds, done by a microsurgical tissue
  transfer/transplant from one part of the body to the other; requires multispecialty approach

    Moles, Skin Cancer and Scar Revisions: The steep increase in skin cancer is directly related to the
exposure to a number of environmental factors, history of previous chemotherapy or radiation treatment.
Your dermatologist should determine the nature of a skin lesion and recommend removal of suspicious
ones. The excision is performed in the office under local anesthesia using sterile instruments. The length
of the scar is determined by the width, orientation and the nature of the skin lesion or subcutaneous
tumor. The direction of the scar is usually made according to the resting skin tension lines so that it
matches as much as possible normal body wrinkles. The resulting wound is closed primarily in
anatomical layers. Sutures are removed after one to three weeks, depending on the location of the
incision. The exception to the above is when the incision is, in selected cases, left to heal on its own, or
when its location and size dictate treatment in the operating room. The pathology report will determine if
further office or operating room re-excision or any other adjuvant treatment will be needed. In order to
minimize scaring and optimize the outcome, modified activity level is needed for about 3 weeks
following mole removal or scar revision.

     I hope you find the information provided here educational. Certainly not all sections outlined here
might be applicable to you but hopefully you may find an answer to some of your questions, or those of a
friend or family member. Please note that when undergoing any of the reconstructive procedures,
cosmetic surgery can be combined during the same operative session, granted I find it appropriate and
safe. Many patients find this convenient and economical especially since the total peri-operative expenses
are significantly lower than when undergoing only aesthetic surgery. If any further information can be
provided to you, please feel free to make an appointment to discuss it. We are always more than happy to
answer any questions you might have.


                                                   Ivica Ducic, MD, PhD
                                               Associate Professor, Plastic Surgery

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