A Novel Strategy to Supercharge a Deep Inferior Epigastric Artery Perforator Flap after Port-a-Cath Removal

Summary: Autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has become increasingly popular because of its unique advantages. However, compared with some other forms of abdominal-based autologous reconstruction, DIEP flaps are associated with an increased risk of venous congestion. Many techniques—or lifeboats—have been introduced to diagnose and treat this potentially devastating complication. In this case report, we describe a novel strategy to augment venous drainage when venous congestion is encountered. A patient presented requesting autologous reconstruction and removal of a venous access catheter that had been used for chemotherapy administration. We performed left delayed breast reconstruction using a single-perforator DIEP flap from the right hemiabdomen. The superficial inferior epigastric vein to this flap was preserved. After removal of the Port-a-Cath from the left chest, we anastomosed the superficial inferior epigastric vein to the fibrous capsular sheath that had formed around the indwelling catheter to allow additional venous drainage. Flow through this conduit was confirmed using Doppler ultrasound. There were no flap-related complications, and the patient was discharged in good condition. Further research is warranted to characterize the indications and limitations of this novel lifeboat.

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An Appraisal of Internal Mammary Artery Perforators as Recipient Vessels in Microvascular Breast Reconstruction—An Analysis of 515 Consecutive Cases

Background: The usage of internal mammary artery perforators (IMAPs) has been described in autologous breast reconstruction although IMAPS are not yet considered standard recipient vessels. It remains unclear if these vessels can be safely used in large flaps after radiation therapy or in delayed breast reconstruction. Methods: Over a 2-year period, 515 free flaps for autologous breast reconstruction were performed on 419 patients by 2 surgeons (S1 and S2). In a retrospective analysis, time of reconstruction, ischemia time, flap weight, diameter of couplers, and complications were analyzed. All 515 flaps were compared in a subset with regard to the 2 surgeons: S1 who always used the IMA as a recipient vessel and S2 who attempted IMAP use if possible. Results: Of all 515 flaps, 424 were abdominal flaps and 91 flaps were from the upper thigh. Three hundred six cases were immediate reconstructions, and 112 were delayed reconstructions. In 97 cases, implants were converted to autologous tissue. In 112 cases, the IMAPs were used; of these, 82 were immediate and 17 were delayed reconstructions, and in 13 cases, implants were removed. Thirty-five percent of all anastomoses to IMAPs had previous radiation therapy. The flap failure rate was 1.9%. In none of these cases, the IMAPs were used. S1 never used the IMAP, and S2 used the IMAP in 37% of all of his flaps. Conclusions: IMAPs were safely used in all kinds of reconstructions and after radiation therapy, with no flap failure or negative effects on mastectomy skin flap perfusion. Using the IMAPs as recipient vessels is a further step toward simplifying microsurgical breast reconstruction.

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Anatomical Regional Targeted (ART) BOTOX Injection Technique: A Novel Paradigm for Migraines and Chronic Headaches

Summary: Migraine headaches are a debilitating disease that causes significant socioeconomic problems. One of the speculated etiologies of the generation of migraines is peripheral nerve irritation at different trigger points. The use of Onabotulinum toxin A (BOTOX), although initially a novel approach, has now been determined to be a valid treatment for chronic headaches and migraines as described in the Phase III Research Evaluating Migraine Prophylaxis Therapy trials that prompted the approval by the Food and Drug Administration for treatment of chronic migraines. The injection paradigm established by this trial was one of a broad injection pattern across large muscle groups that did not always correspond to the anatomical locations of nerves. The senior author developed the Anatomical Regional Targeted BOTOX injection paradigm as an alternative to the current injection model. This technique targets both the anatomical location of nerves known to have causal effects with migraines and the region where the pain localizes, to provide relief across a wide distribution of the peripheral nerve. This article serves as a guide to the Anatomical Regional Targeted injection technique, which, to our knowledge, is the first comprehensive BOTOX injection paradigm described in the literature for treatment of migraines that targets nerves and nerve areas rather than purely muscle groups. This technique is based on the most up-to-date anatomical and scientific studies and large-volume migraine surgery experience.

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All Seasons Vertical Augmentation Mastopexy: A Simple Algorithm, Clinical Experience, and Patient-reported Outcomes

Background: The safety of augmentation mastopexy has been questioned. Staging has been recommended for women deemed to be at higher risk, such as women with greater degrees of ptosis. Most existing studies evaluate women treated with multiple methods, including the traditional Wise pattern. This retrospective study specifically evaluates vertical augmentation mastopexy. A simple algorithm is introduced. Methods: From 2002 to 2016, 252 women underwent consecutive vertical augmentation mastopexies performed by the author, with no staged surgery. All patients underwent a vertical mastopexy using a medially based pedicle and intraoperative nipple siting. A subset of women treated from 2012 to 2016 were surveyed to obtain outcome data; 90 patients (inclusion rate, 90%) participated. Results: The complication rate was 32.9%, including persistent ptosis, delayed wound healing, scar deformities, and asymmetry. There were no cases of nipple loss. An increased risk of complications was detected for smokers (P

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Intermediate Phenotype between ADULT Syndrome and EEC Syndrome Caused by R243Q Mutation in TP63

Summary: A patient who had ectrodactyly, dry skin, exfoliative dermatitis, and hypodontia with peg-shaped teeth, but not cleft lip and palate, is described. Ectrodactyly with a tooth anomaly is recognized in both acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome and ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome. These 2 syndromes are caused by heterozygous mutations in the transcriptional factor gene p63. Mutation analysis of p63 gene showed a heterozygous mutation c.728G>A, p.Arg243Gln (previously referred to as R204Q) in the patient, but not in his parents. Therefore, this was a sporadic case of the p63 mutation–associated disorder. Although the mutation has been mostly reported in EEC syndrome patients, the present case did not have cleft lip and palate. Furthermore, the present case did not exhibit freckling or some of the other ectodermal dysplasia phenotypes typical of ADULT syndrome. The concept of ELA syndrome proposed by Prontera in 2011 resolves the problem confronted in diagnosing the present case. ELA syndrome is an acronym of EEC/limb–mammary syndrome/ADULT syndromes, and these 3 syndromes are united into a unique entity. This system can classify p63 mutation–associated disorders simply without interfering with treatment.

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Aesthetic Applications of Botulinum Toxin A in Asians: An International, Multidisciplinary, Pan-Asian Consensus

Background: Botulinum toxin type A remains the most popular nonsurgical aesthetic treatment worldwide. Previous consensus statements have focused on Caucasians and on Koreans as generally representative of Asians. However, indications and dosages vary among different ethnic groups. This publication reports the results of a multidisciplinary, pan-Asian consensus focusing on incobotulinumtoxinA. Methods: A consensus group of plastic surgeons and dermatologists from Asia, Europe, and the United States convened for a live meeting in Asia, followed by a questionnaire-based Delphi procedure. Treatment of Asians in both their native countries and countries of migration was discussed. Results: For most items, the group achieved a majority consensus. A number of treatment indications, strategies, and dosages were identified in Asians, which are distinct to those previously described for Caucasians due to differences in facial morphotypes, anatomy, and cultural expectations. The group also formulated position statements for intradermal botulinum toxin type A ("mesotoxin"), body shaping with the calves as a paradigm, and reduction of parotid glands. While Asians have previously been considered a homogeneous group for the purposes of aesthetic treatment, this publication considers regional variations. A new classification of Asian facial morphotypes is proposed to aid treatment planning and implementation. Conclusions: This is the first pan-Asian consensus for aesthetic use of botulinum toxin type A. Its unique objective is to optimize treatment safety and efficacy for patients of complete or part-Asian ancestry in all regions. The recommendations for incobotulinumtoxinA may be extended with care to other botulinum toxin formulations.

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Repair of Large Abdominal Wall Defects Using Total Anterior Aponeurotic Flap: Anatomical Feasibility Study and Comparison with Ramirez’s Technique

Summary: In this cadaveric study, we explored the feasibility of a maximal mobilization of the superficial abdominal fascia, in a continuous flap, to achieve a tension-free covering of midline defects. The aponeurosis of the external oblique muscle was incised along the anterior axillary line and then detached up to the anterior rectus sheath. The latter was opened between the external and the internal oblique aponeurosis while keeping the continuity with the external oblique fascia. The obtained flap was solid and uninterrupted. The width gain reached 15 ± 3 cm on each sides, providing tissue advancement 60% longer than Ramirez's technique (n = 8). The described technique allows large covering with respect to the anatomical planes. Further clinical tests should evaluate the validity of such concept in the repair of giant and asymmetrical hernias.

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The Number of Perforators Included in Reversed Flow Posterior Interosseous Artery Flap: Does It Affect the Incidence of Venous Congestion?

Background: The purpose of this study is to decrease the incidence of venous congestion occurring in the reversed flow posterior interosseous artery flap used for coverage of hand defects. Methods: This may be achieved by studying the incidence of venous congestion in flaps including only 1 perforator and comparing the results with others including more than 1 perforator both in small and large sized flaps. Results: This study showed that inclusion of only 1 perforator in the flap decreased the incidence of venous congestion with complete flap loss in flaps to 5%. Also, it decreased the incidence of venous congestion with partial flap loss in flaps to 10%. Conclusions: The small sized reversed flow posterior interosseous artery flap should be less than 40 cm2 and should include only 1 perforator to decrease the incidence of venous congestion with partial and complete loss of the flap. The level of evidence for this study is the type II prospective comparative study.

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Technique to Improve Tracheostomy Speaking Valve Tolerance after Head and Neck Free Flap Reconstruction

Summary: Increased upper airway resistance from postoperative changes after major head and neck surgery may cause elevated transtracheal pressures and result in tracheostomy speaking valve intolerance. This may be particularly true among patients with baseline pulmonary disease. We describe a patient recovering from oral cancer resection and flap reconstruction who demonstrated prolonged ventilator dependence and tracheostomy speaking valve intolerance with abnormal tracheal manometry. We attempted to improve speaking valve tolerance through the adaptation of a valve modification intended to reduce transtracheal pressures. Drilling holes into the 1-way speaking valve allowed for excess air egress and resulted in normalization of transtracheal pressures with improved speaking valve tolerance. This 1-way speaking valve modification may serve as a simple method to allow for earlier restoration of voicing and potentially reduce the number of ventilator- dependent days in this patient population.

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Regenerative Peripheral Nerve Interfaces for the Treatment of Postamputation Neuroma Pain: A Pilot Study

Background: Originally designed for prosthetic control, regenerative peripheral nerve interfaces (RPNIs) prevent neuroma formation by providing free muscle grafts as physiological targets for peripheral nerve ingrowth. We report the first series of patients undergoing RPNI implantation for treatment of symptomatic postamputation neuromas. Methods: A retrospective case series of all amputees undergoing RPNI implantation for treatment of symptomatic neuromas between November 2013 and June 2015 is presented. Data were obtained via chart review and phone interviews using questions derived from the Patient Reported Outcomes Measurement Information System instruments. Statistical analyses were performed using dependent sample t tests with a significance threshold of P

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Is Rigid Nasal Splinting Needed after Rhinoplasties? An 18-year Experience Using Surgical Tape

No abstract available

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Disparities in Utilization of Jaw Surgery for Treatment of Sleep Apnea: A Nationwide Analysis

Background: Maxillomandibular advancement has been shown to be one of the most effective operations for management of severe obstructive sleep apnea, yet pharyngeal surgery is more commonly performed. The goal of this study was to identify socioeconomic factors associated with this phenomenon. Methods: Patients aged 14 or older with a primary hospital diagnosis of sleep apnea were identified using the National Inpatient Sample from 2005 to 2012. ICD9 codes were used to determine whether a pharyngeal or jaw procedure was performed. Patient demographics, comorbidities, and complications were compared. Results: Among 6316 sleep surgeries, 5964 (94.4%) were pharyngeal and 352 (5.6%) were jaw procedures. Women were significantly more likely to receive jaw surgery than men (odds ratio [OR] = 1.68, P = 0.0007). African Americans (OR = 0.19, P

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De Novo Reconstruction of a Hybrid Patella by Staged Fabrication of a Microvascular Bone Transplant with an Osteointegrated Prosthetic Socket

Summary: Total patellectomy is sometimes unavoidable but usually results in severely impaired function, pain, and instability in the affected knee. Any patellar prosthetic solutions rely on a certain amount of remaining bone and therefore are not applicable after total patellectomy. Traditionally, reconstruction of a neopatella by avascular or allogeneic bone grafts is hampered by mechanical failure, resorption, or infection. We developed a new, 3-stage approach to reconstruct a hybrid patella composed of a revascularized scapula tip transplant fabricated with a prosthetic socket. The procedure is safe and provides optimal healing and prosthetic osteointegration through viable bone and dynamic stability to the considerable load a patella has to bear in unrestricted mobility. The technique also demonstrates successful integration of orthopedic prosthetic devices into current flap fabrication concepts.

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Accurate Measurements of the Skin Surface Area of the Healthy Auricle and Skin Deficiency in Microtia Patients

Background: The limited cranial skin covering auricular implants is an important yet underrated factor in auricular reconstruction for both reconstruction surgery and tissue engineering strategies. We report exact measurements on skin deficiency in microtia patients and propose an accessible preoperative method for these measurements. Methods: Plaster ear models (n = 11; male:female = 2:1) of lobular-type microtia patients admitted to the University Medical Center Utrecht in The Netherlands were scanned using a micro-computed tomographic scanner or a cone-beam computed tomographic scanner. The resulting images were converted into mesh models from which the surface area could be calculated. Results: The mean total skin area of an adult-size healthy ear was 47.3 cm2, with 49.0 cm2 in men and 44.3 cm2 in women. Microtia ears averaged 14.5 cm2, with 15.6 cm2 in men and 12.6 cm2 in women. The amount of skin deficiency was 25.4 cm2, with 26.7 cm2 in men and 23.1 cm2 in women. Conclusions: This study proposes a novel method to provide quantitative data on the skin surface area of the healthy adult auricle and the amount of skin deficiency in microtia patients. We demonstrate that the microtia ear has less than 50% of skin available compared with healthy ears. Limited skin availability in microtia patients can lead to healing problems after auricular reconstruction and poses a significant challenge in the development of tissue-engineered cartilage implants. The results of this study could be used to evaluate outcomes and investigate new techniques with regard to tissue-engineered auricular constructs.

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Endoscopic excision of a giant pleomorphic adenoma of the nasal septum

Publication date: Available online 9 January 2017
Source:Egyptian Journal of Ear, Nose, Throat and Allied Sciences
Author(s): Ramaprabah Kandiah, Pathma Letchumanan, Harvinder Singh, Baharudin Abdullah
Pleomorphic adenoma of nasal cavity is very rare. Approximately 80% is found in the nasal septum while the remaining 20% is found in the lateral nasal wall. Histologically, pleomorphic adenoma of the nasal cavity differs from the tumor arising from the major salivary glands. It contains more cellularity and epithelial components than the stromal elements. The treatment is total excision with long term follow up as there is potential risk of recurrence and malignancy. Endonasal endoscopic excision has lesser morbidity with better prognosis. In this case report, we highlighted the successful endoscopic excision of an extensive posteriorly located pleomorphic adenoma.



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Reconstruction of an extensive iliac thigh defect with a giant combined thigh perforator free flap

Abstract

Cases with vast skin defects that cannot be covered by a single flap use the combination of two neighboring flaps. An extensive iliac thigh degloving injury was reconstructed with the combined flap formed by the anterolateral thigh flap and the tensor fasciae latae perforator flap, resulting in a functionally and aesthetically good outcome. This combined flap has minimum donor site morbidity and can be thinned as required. The combined flap consisting of the anterolateral thigh flap and the tensor fasciae latae perforator flap is considered suitable for the repair of massive skin soft tissue defects.

Level of Evidence: Level V, therapeutic study.

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Effect of differential surface anisotropy on performance of two plate shaped crystals of aspirin form I

Publication date: 1 March 2017
Source:European Journal of Pharmaceutical Sciences, Volume 99
Author(s): Tanshu Jain, Sneha Sheokand, Sameer R. Modi, Bharat Ugale, Ram Naresh Yadav, Navin Kumar, C.M. Nagaraja, Arvind K. Bansal
Differential surface anisotropy of different crystals of the same API can have a significant impact on their pharmaceutical performance. The present work investigated the impact of differential surface anisotropy of two plate-shaped crystals of aspirin (form I) on their hygroscopicity, stability and compaction behavior. These crystals differed in their predominant facets (100) and (001) and were coded as AE-100 & E-001. (100) facets exposed polar carbonyl groups which provided hydrophilicity to the facets. In contrast, (001) facets possessed hydrophobicity as they exposed non-polar aryl and methyl groups. Both the samples showed different degradation behavior, at various stability conditions (i.e. 40°C/75%RH, 30°C/90%RH and 30°C/60%RH) and different time intervals. Polar groups of aspirin have been reported to be prone to hydrolysis due to which AE-100 was less stable than E-001. Dynamic vapor sorption (DVS) analysis at different simulated stability conditions also supported this observation, wherein AE-100 showed higher moisture sorption than E-001. Both the samples having similar particle size, shape, surface area and hardness value, showed differences in their compactibility. However, milling narrowed down the predominance of facets and both the milled samples showed similar stability and compaction behavior. This study was also supported by surface free energy determination, molecular modeling and face indexation of unmilled and milled samples.

Graphical abstract

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Preparation of curcumin-loaded PCL-PEG-PCL triblock copolymeric nanoparticles by a microchannel technology

Publication date: 1 March 2017
Source:European Journal of Pharmaceutical Sciences, Volume 99
Author(s): Fangyuan Guo, Dingjia Guo, Wei Zhang, Qinying Yan, Yan Yang, Weiyong Hong, Gensheng Yang
Biodegradable polymeric nanoparticles (NPs) have potential therapeutic applications; however, preparing NPs of a specific diameter and uniform size distribution is a challenge. In this work, we fabricated a microchannel system for the preparation of curcumin (Cur)-loaded NPs by the interfacial precipitation method, which rapidly and consistently generated stable NPs with a relatively smaller diameter, narrow size distribution, and higher drug-loading capacity and entrapment efficiency. Poly(ε-caprolactone)-poly(ethylene glycol)-poly (ε-caprolactone) triblock copolymers(PCEC) used as the carrier material was synthesized and characterized. Cur-loaded PCEC NPs had an average size of 167.2nm with a zeta potential of −29.23mV, and showed a loading capacity and drug entrapment efficiency of 15.28%±0.23% and 96.11%±0.13%, respectively. Meanwhile, the NPs demonstrated good biocompatibility and bioavailability, efficient cellular uptake, and long circulation time and a possible liver targeting effect in vivo. These results indicate that the Cur-loaded PCEC NPs can be used as drug carriers in controlled delivery systems and other biomedical applications.

Graphical abstract

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Lack of genetic association between OCT1, ABCB1, and UGT2B7 variants and morphine pharmacokinetics

Publication date: 1 March 2017
Source:European Journal of Pharmaceutical Sciences, Volume 99
Author(s): LM Nielsen, E Sverrisdóttir, TB Stage, S Feddersen, K Brøsen, LL Christrup, AM Drewes, AE Olesen
AimA high inter-individual variation in the pharmacokinetics and pharmacodynamics of morphine has been observed. Genetic polymorphisms in genes encoding the organic cation transporter isoform 1 (OCT1), the efflux transporter p-glycoprotein (ABCB1), and the UDP-glucuronosyltransferase-2B7 (UGT2B7) may influence morphine pharmacokinetics and thus, also pharmacodynamics. The aim of this study was to evaluate the association between OCT1, ABCB1, and UGT2B7 variants, and morphine pharmacokinetics and -dynamics in healthy volunteers.MethodsPharmacokinetic and pharmacodynamic data were collected from a double-blinded, randomized, crossover trial in 37 healthy subjects. Pharmacokinetic data were analyzed in NONMEM®, and the time-concentration relationship of morphine, morphine-3-glucuronide, and morphine-6-glucuronide was parameterized as the transit compartment rate constant (ktr), clearance (CL), and volume of distribution (VD). The area under the plasma concentration-time curve (AUC0–150min) and the maximum plasma concentration (Cmax) were also calculated. Pharmacodynamic data were measured as pain tolerance thresholds to mechanical stimulation of the rectum and muscle, as well as tonic cold pain stimulation ("the cold pressor test" where hand was immersed in cold water). Six different single nucleotide polymorphisms in three different genes (OCT1 (n=22), ABCB1 (n=37), and UGT2B (n=22)) were examined.ResultsNeither AUC0–150min, ktr, CL, nor VD were associated with genetic variants in OCT1, ABCB1, and UGT2B7 (all P>0.05). Similarly, the antinociceptive effects of morphine on rectal, muscle, and cold pressor tests were not associated with these genetic variants (all P>0.05).ConclusionsIn this experimental study in healthy volunteers, we found no association between different genotypes of OCT1, ABCB1, and UGT2B7, and morphine pharmacokinetics and pharmacodynamics. Nonetheless, due to methodological limitations we cannot exclude that associations exist.

Graphical abstract

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Negative Regulation of Type 2 Immunity

Publication date: Available online 9 January 2017
Source:Trends in Immunology
Author(s): Dimitri A. de Kouchkovsky, Sourav Ghosh, Carla V. Rothlin
Type 2 immunity encompasses the mechanisms through which the immune system responds to helminths and an array of environmental substances such as allergens. In the developing world, billions of individuals are chronically infected with endemic parasitic helminths. In comparison, in the industrialized world, millions of individuals suffer from dysregulated type 2 immunity, referred to clinically as atopic diseases including asthma, allergic rhinitis, and atopic dermatitis. Thus, type 2 immunity must be carefully regulated to mount protective host responses yet avoid inappropriate activation and immunopathology. In this review, we describe the key players and connections at play in type 2 responses and focus on the emerging mechanisms involved in the negative regulation of type 2 immunity.



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