Head and Neck Diseases by Alexandros G.Sfakianakis: 02/09/17

Πέμπτη 9 Φεβρουαρίου 2017

Homozygous Loss of Autism-Risk Gene CNTNAP2 Results in Reduced Local and Long-Range Prefrontal Functional Connectivity

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Functional connectivity aberrancies, as measured with resting-state functional magnetic resonance imaging (rsfMRI), have been consistently observed in the brain of autism spectrum disorders (ASD) patients. However, the genetic and neurobiological underpinnings of these findings remain unclear. Homozygous mutations in <span style="font-style:italic;">contactin associated protein-like 2</span> (<span style="font-style:italic;">CNTNAP2</span>), a neurexin-related cell-adhesion protein, are strongly linked to autism and epilepsy. Here we used rsfMRI to show that homozygous mice lacking <span style="font-style:italic;">Cntnap2</span> exhibit reduced long-range and local functional connectivity in prefrontal and midline brain "connectivity hubs." Long-range rsfMRI connectivity impairments affected heteromodal cortical regions and were prominent between fronto-posterior components of the mouse default-mode network, an effect that was associated with reduced social investigation, a core "autism trait" in mice. Notably, viral tracing revealed reduced frequency of prefrontal-projecting neural clusters in the cingulate cortex of <span style="font-style:italic;">Cntnap2</span><sup>−/−</sup> mutants, suggesting a possible contribution of defective mesoscale axonal wiring to the observed functional impairments. Macroscale cortico-cortical white-matter organization appeared to be otherwise preserved in these animals. These findings reveal a key contribution of ASD-associated gene CNTNAP2 in modulating macroscale functional connectivity, and suggest that homozygous loss-of-function mutations in this gene may predispose to neurodevelopmental disorders and autism through a selective dysregulation of connectivity in integrative prefrontal areas.</span>

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Body Topography Parcellates Human Sensory and Motor Cortex

<span class="paragraphSection"><div class="boxTitle">Abstract</div>The cytoarchitectonic map as proposed by Brodmann currently dominates models of human sensorimotor cortical structure, function, and plasticity. According to this model, primary motor cortex, area 4, and primary somatosensory cortex, area 3b, are homogenous areas, with the major division lying between the two. Accumulating empirical and theoretical evidence, however, has begun to question the validity of the Brodmann map for various cortical areas. Here, we combined in vivo cortical myelin mapping with functional connectivity analyses and topographic mapping techniques to reassess the validity of the Brodmann map in human primary sensorimotor cortex. We provide empirical evidence that area 4 and area 3b are not homogenous, but are subdivided into distinct cortical fields, each representing a major body part (the hand and the face). Myelin reductions at the hand–face borders are cortical layer-specific, and coincide with intrinsic functional connectivity borders as defined using large-scale resting state analyses. Our data extend the Brodmann model in human sensorimotor cortex and suggest that body parts are an important organizing principle, similar to the distinction between sensory and motor processing.</span>

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The Relation Between Long-Term Synaptic Plasticity at Glutamatergic Synapses in the Amygdala and Fear Learning in Adult Heterozygous BDNF-Knockout Mice

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Brain-derived neurotrophic factor (BDNF) heterozygous knockout mice (BDNF<sup>+/−</sup> mice) show fear learning deficits from 3 months of age onwards. Here, we addressed the question how this learning deficit correlates with altered long-term potentiation (LTP) in the cortical synaptic input to the lateral amygdala (LA) and at downstream intra-amygdala synapses in BDNF<sup>+/-</sup> mice. Our results reveal that the fear learning deficit in BDNF<sup>+/−</sup> mice was not paralleled by a loss of LTP, neither at cortical inputs to the LA nor at downstream intra-amygdala glutamatergic synapses. As we did observe early fear memory (30 min after training) in BDNF<sup>+/−</sup> mice while long-term memory (24 h post-training) was absent, the stable LTP in cortico-LA and downstream synapses is in line with the intact acquisition of fear memories. Ex vivo recordings in acute slices of fear-conditioned wildtype (WT) mice revealed that fear learning induces long-lasting changes at cortico-LA synapses that occluded generation of LTP 4 and 24 h after training. Overall, our data show that the intact LTP in the tested amygdala circuits is consistent with intact acquisition of fear memories in both WT and BDNF<sup>+/−</sup> mice. In addition, the lack of learning-induced long-term changes at cortico-LA synapses in BDNF<sup>+/−</sup> mice parallels the observed deficit in fear memory consolidation.</span>

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Cognitive Enhancement Induced by Anodal tDCS Drives Circuit-Specific Cortical Plasticity

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Increasing evidence shows that anodal transcranial direct current stimulation (tDCS) enhances cognitive performance in healthy and clinical population. Such facilitation is supposed to be linked to plastic changes at relevant cortical sites. However, direct electrophysiological evidence for this causal relationship is still missing. Here, we show that cognitive enhancement occurring in healthy human subjects during anodal tDCS is affected by ongoing brain activity, increasing cortical excitability of task-related brain networks only, as directly measured by Transcranial Magnetic Stimulation combined with electroencephalography (TMS-EEG). Specifically, TMS-EEG recordings were performed before and after anodal tDCS coupled with a verbal fluency task. To control for effects of tDCS protocol and TMS target location, 3 conditions were assessed: anodal/sham tDCS with TMS over left premotor cortex, anodal tDCS with TMS over left posterior parietal cortex. Modulation of cortical excitability occurred only at left Brodmann's areas 6, 44, and 45, a key network for language production, after anodal tDCS and TMS over the premotor cortex, and was positively correlated to the degree of cognitive enhancement. Our results suggest that anodal tDCS specifically affects task-related functional networks active while delivering stimulation, and this boost of specific cortical circuits is correlated to the observed cognitive enhancement.</span>

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A Systematic Relationship Between Functional Connectivity and Intracortical Myelin in the Human Cerebral Cortex

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Research in the macaque monkey suggests that cortical areas with similar microstructure are more likely to be connected. Here, we examine this link in the human cerebral cortex using 2 magnetic resonance imaging (MRI) measures: quantitative <span style="font-style:italic;">T</span><sub>1</sub> maps, which are sensitive to intracortical myelin content and provide an in vivo proxy for cortical microstructure, and resting-state functional connectivity. Using ultrahigh-resolution MRI at 7 T and dedicated image processing tools, we demonstrate a systematic relationship between <span style="font-style:italic;">T</span><sub>1</sub>-based intracortical myelin content and functional connectivity. This effect is independent of the proximity of areas. We employ nonlinear dimensionality reduction to characterize connectivity components and identify specific aspects of functional connectivity that are linked to myelin content. Our results reveal a consistent spatial pattern throughout different analytic approaches. While functional connectivity and myelin content are closely linked in unimodal areas, the correspondence is lower in transmodal areas, especially in posteromedial cortex and the angular gyrus. Our findings are in agreement with comprehensive reports linking histologically assessed microstructure and connectivity in different mammalian species and extend them to the human cerebral cortex in vivo.</span>

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Medial Frontal Circuit Dynamics Represents Probabilistic Choices for Unfamiliar Sensory Experience

<span class="paragraphSection"><div class="boxTitle">Abstract</div>Neurons in medial frontal cortex (MFC) receive sensory signals that are crucial for decision-making behavior. While decision-making is easy for familiar sensory signals, it becomes more elaborative when sensory signals are less familiar to animals. It remains unclear how the population of neurons enables the coordinate transformation of such a sensory input into ambiguous choice responses. Furthermore, whether and how cortical oscillations temporally coordinate neuronal firing during this transformation has not been extensively studied. Here, we recorded neuronal population responses to familiar or unfamiliar auditory cues in rat MFC and computed their probabilistic evolution. Population responses to familiar sounds organize into neuronal trajectories containing multiplexed sensory, motor, and choice information. Unfamiliar sounds, in contrast, evoke trajectories that travel under the guidance of familiar paths and eventually diverge to unique decision states. Local field potentials exhibited beta- (15–20 Hz) and gamma-band (50–60 Hz) oscillations to which neuronal firing showed modest phase locking. Interestingly, gamma oscillation, but not beta oscillation, increased its power abruptly at some timepoint by which neural trajectories for different choices were near maximally separated. Our results emphasize the importance of the evolution of neural trajectories in rapid probabilistic decisions that utilize unfamiliar sensory information.</span>

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β-Catenin in the Adult Visual Cortex Regulates NMDA-Receptor Function and Visual Responses

<span class="paragraphSection"><div class="boxTitle">Abstract</div>The formation, plasticity and maintenance of synaptic connections is regulated by molecular and electrical signals. β-Catenin is an important protein in these events and regulates cadherin-mediated cell adhesion and the recruitment of pre- and postsynaptic proteins in an activity-dependent fashion. Mutations in the β-catenin gene can cause cognitive disability and autism, with life-long consequences. Understanding its synaptic function may thus be relevant for the treatment of these disorders. So far, β-catenin's function has been studied predominantly in cell culture and during development but knowledge on its function in adulthood is limited. Here, we show that ablating β-catenin in excitatory neurons of the adult visual cortex does not cause the same synaptic deficits previously observed during development. Instead, it reduces NMDA-receptor currents and impairs visual processing. We conclude that β-catenin remains important for adult cortical function but through different mechanisms than during development.</span>

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An unusual cause of food-induced anaphylaxis in mothers

Galacto-oligosaccharides (GOS) are prebiotics added to commercial milk formula of infants and mothers. In recent years, cases of allergy related to GOS in atopic children have been reported in the South East A...

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An unusual cause of food-induced anaphylaxis in mothers

Progress with Structure-Activity Relationship modelling of occupational chemical respiratory sensitizers.

Purpose of review: This appraises currently available computer-based ('in silico') models relating the molecular structure of low molecular weight compounds to their respiratory sensitization hazard. The present review places focus on the two main applications of such structure--activity relationship (SAR) models: hypotheses on disease mechanisms and toxicological prediction. Recent findings: Analyses of the chemical structures of low molecular weight organic compounds known to have caused occupational asthma has led to the development of mechanistic alerts usually based on electrophilic reaction chemistry and protein cross-linking potential. Protein cross-linking potential has also been found to be a consistent feature of chemicals that have caused human cases of hypersensitivity pneumonitis. Stepwise iteration of quantitative SAR (QSAR) modelling has shown appreciable improvements in predictivity for occupational asthma hazard and useful prospects for practical application. A good case has also been made for the potential use of structural alert-based mechanistic SARs in predictive toxicology. Summary: Further understanding of the molecular interactions between chemical respiratory sensitizers and components of human proteins has been obtained from in-vitro and in-silico techniques. There have been developments in both qualitative (mechanistic) SARs and QSARs, which offer potential for use in a predictive algorithm for the toxicological screening of industrial chemicals for respiratory sensitization potential. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Building school health partnerships to improve pediatric asthma care: the school-based asthma management program.

Purpose of review: Children with asthma require care that is seamlessly coordinated so that asthma symptoms are recognized and managed at home and at school. The purpose of this review is to discuss recent consensus recommendations in school-based asthma care. Recent findings: The School-based Asthma Management Program (SAMPRO(TM)) provides a widely endorsed framework to coordinate care with schools and consists of four components: establishing a circle of support around the child with asthma; facilitating bidirectional communication between clinicians and schools; comprehensive asthma education for schools; and assessment and remediation of environmental asthma triggers at school. SAMPRO standardizes recommendations for school-based asthma care coordination and provides a toolkit with websites and resources useful for the care of children with asthma in the school setting. Summary: The review will discuss the need for coordinated school asthma partnerships, the inception and development of SAMPRO, and its vision to improve pediatric asthma care coordination within the circle of support, comprised of clinicians, school nurses, families, and communities. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Silicosis and autoimmunity.

Purpose of review: Of the various environmental, occupational, and medical substances that cause dysregulation of autoimmunity, the effects and causative mechanisms of silica particles and asbestos fibers are discussed in this review. Recent findings: With respect to silica, many epidemiological studies have shown a significant association between silica exposure and the occurrence of autoimmune diseases. Although the importance of the NACHT, LRR and PYD domains-containing protein 3 (NALP3) inflammasome as the initial immune reaction against silica particles has been identified, the mechanisms involved that lead to various autoimmune diseases in patients exposed to silica remain largely unknown. Silica can activate various immune cells and investigation of the associated imbalance of regulatory T cells, responder T cells as well as Th17 cells might be key in furthering our understanding of silica-induced autoimmune alterations. On the other hand, asbestos exposure shows less association with autoimmune diseases. However, interesting findings pertaining to the detection of antiendothelial and mesothelial cell antibodies in asbestos-exposed patients have been reported. Summary: Taken together, further investigations may contribute in delineating the mechanisms involved in environmental factor-induced modification of autoimmunity. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Progress with Structure-Activity Relationship modelling of occupational chemical respiratory sensitizers.

Building school health partnerships to improve pediatric asthma care: the school-based asthma management program.

Silicosis and autoimmunity.

Bilateral Leg Replantation in a 3-Month-Old Baby After a Knee Level Crush Amputation—A 2-Year Follow-up

Abstract: We present a case of a successful bilateral leg replantation in a 3-month-old baby after a knee-level crush amputation with the loss of both knee joints. The legs were replanted after 4 hours of warm and an additional 2.5 and 3.5 hours of cold ischemia time. Both legs show motor and sensory reinnervation, without additional procedures performed on the right leg, and after a nerve reconstruction with cadaveric allografts on the left leg. Both replanted legs exhibit excellent bony and soft tissue growth. Two years after the injury, the patient is progressing well with rehabilitation, with favourable odds of having knee reconstructions performed at a later age. This is the youngest patient reported to have had successful replantation of both legs.

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Maximizing the Reach of the Pedicled Gastrocnemius Muscle Flap: A Comparison of 2 Surgical Approaches

Background: The medial gastrocnemius muscle flap is commonly used for the reconstruction of defects around the knee and proximal leg. The flap can be raised using either a medial or a posterior midline incision, although no studies have been done comparing the 2 different surgical approaches. Methods: We compared the reach of the medial gastrocnemius muscle flap using either of the 2 incisions in a series of 25 fresh cadavers. All muscle flaps were elevated without division of the muscle origin. Muscle reach was calculated using the distance from a fixed bony point with the leg fully extended and the muscle under no tension. Muscle width measurements were used to calculate surface area of coverage. Results: Muscle flaps elevated through the posterior midline incision group reached 2.02 cm farther than flaps through the medial incision (P

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Book Review: 100 Hand Cases

No abstract available

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The Relationship Between Geographic Access to Plastic Surgeons and Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer

Introduction: Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. Methods: Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. Results: The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0–2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%–62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P

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Modified Direct-Type Septal Extension Grafts: Their Stability and Usefulness in Asian Rhinoplasty

Background: In Asian rhinoplasty, many autogenous cartilage grafts are required for correction of the nasal tip and columella, but the amount has limitations. A modified direct-type septal extension graft, in continuity with the entire caudal border of the septal cartilage with an edge-to-edge coaptation, can effectively and concomitantly correct the nasal tip and columella deformities using a limited amount of septal cartilage graft. The purpose of this study was to evaluate long-term cosmetic outcomes and stability from the modified direct extension grafts. Methods: Fifty-seven patients with a follow-up of more than 1 year were enrolled in the study. A total of 11 measurement items were evaluated from basal and right lateral views by photogrammetry using standardized clinical photographic techniques. Results: The overall mean follow-up period was 20.4 months. When comparing the preoperative and postoperative values, the nasal tip projection, nasal bridge length, nasal tip angle, height of nose, and the columellar labial angle increased significantly; additionally, the soft nose width index, width between ac-ac index, nostril axis inclination, columellar length (Rt-Lt), and the alar length (Rt-Lt) decreased significantly. No resorption, buckling, or displacement of the graft was observed during the follow-up period. Conclusions: The modified direct extension graft demonstrated a marked aesthetic improvement in the nasal tip and columella, and it provided long-term stability. Therefore, the modified direct extension graft is useful for correction of the nasal tip and columella in Asian rhinoplasty.

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Research Disparities in Female-to-Male Transgender Genital Reconstruction: The Charge for High-Quality Data on Patient Reported Outcome Measures

No abstract available

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Chest Surgery in Female to Male Transgender Individuals

Background: Societal awareness of transgender individuals has led to increased acceptance and demand for sex-confirming surgery. In female to male transsexuals, the most common procedure is removal of breast tissue to masculinize the chest. Methods: Eighty-eight transgender patients underwent either a subcutaneous nipple-sparing mastectomy (NSM) with or without a periareolar mastopexy or nipple reduction, or bilateral mastectomies with free nipple grafts (MFNG) with or without nipple reduction. Surgical techniques are discussed. Demographic data, use of testosterone, specimen weights, rates of wound dehiscence, infection, hematoma, hypertrophic scars, nipple loss, and revision surgery were all assessed. Results: Of the 88 patients in the study, 40 underwent NSM and 48 underwent MFNG. Patients undergoing NSM were 4.1 times more likely to have a hematoma compared with patients undergoing MFNG (P 0.80). Only 1 patient who underwent NSM required revision, whereas 5 patients in the MFNG patient population underwent revision. Patients were more likely to have hypertrophic scarring with the MFNG technique (0% vs 25%, P

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Linear Separation of Toe Syndactyly With Preserved Subcutaneous Vascular Network Skin Grafts

Background: Conventional surgery of toe syndactyly is accomplished using a zig-zag incision and full thickness or split thickness skin grafting. However, this method has an aesthetic problem with a prominent scar on the dorsal side of the foot. The aim of the article was to investigate the efficacy of a cosmetically conscious operation for syndactylies performed using a single technique. Methods: A retrospective analysis was performed involving 66 patients with 88 syndactylic toes who presented to the department of plastic and reconstructive surgery at 1 of 3 major institutions during a 16-year period (1998–2014). Syndactylies were classified according to the affected interdigital spaces (IDSs). All cases were treated using the same method: linear skin incisions to divide the digits, triangular flaps on the dorsal and plantar sides of the foot, and preserved subcutaneous vascular network skin grafts from the medial inframalleolar region. Results: The most frequent type of toe syndactyly was IDS-2 (union of the second/third toes), which accounted for 59.1% (39/66) of the cases. The rates of familial anomalies were significantly different between bilateral IDS-2 (4/13) and unilateral IDS-2 (0/24) (P

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Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use?

Introduction: The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period. Methods: A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013–2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications. Results: We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m2, and those without abdominal mesh placed at the time of donor site closure in the TAP block group. Conclusions: Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

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Aging Changes of the Male Lips—A Lesser Evil Than in Females?

Background: Although aging changes of the female perioral region and aesthetic procedures for perioral rejuvenation are described in literature, specific data for the male population are lacking. This study aims to evaluate perioral aging process in the male population to compare quality and quantity of the observed changes to the female population. Methods: Magnetic resonance imaging (MRI) scans of 22 male subjects, were recruited into 2 age groups: young (20–35 years) and old (65–80 years) and the following parameters were measured: length of visible upper lip, thickness of upper lip at the level of vermilion border, thickness of upper lip at the level of the mid lip, and cross-section area of upper lip. Cadaver transverse sections of the upper lip of 10 individuals in 2 age groups, young (80 years, n = 5) underwent histological analysis of the relevant anatomical structures. Results: The MRI analyses does not show a statistically significant difference in upper lip lengths of old and young subjects (P = 0.213). Upper lip thickness decreases statistically significant (P

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The Impact of Diabetes Mellitus on Wound Healing in Breast Reconstruction

Background: Although diabetes mellitus (DM) is a known risk factor for surgical complications in general, there is little published evidence to establish such an effect among patients undergoing breast reconstruction (BR). The purpose of this study was to assess the impact of DM on complications in patients undergoing postmastectomy BR. Methods: Patients who underwent BR at our institution from November 2002 to November 2012 were identified. Clinical and demographic data of patients with type 1 or type 2 DM were reviewed. Complications occurring within 60 days of surgery were compared between diabetic and nondiabetic patients for both autologous and nonautologous reconstruction types. Results: A total of 1371 BR were performed in 1035 patients. There were 877 (64.0%) autologous reconstructions and 494 (36.0%) implant-based reconstructions. Patients with DM (n = 64) had significantly higher preoperative blood glucose levels (137.5 vs 100.1, P

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Osmidrosis Treatment Approaches: A Systematic Review and Meta-Analysis

Background: There are many treatment modalities associated with osmidrosis. The purpose of this study was to identify and compare effective osmidrosis treatments. Methods: A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. The osmidrosis treatment modalities were extracted as predictor variables, and recurrence and complications were extracted as outcome variables. Subgroup analysis was performed with regard to combined curettage, and fixed and random effect models were applied. Results: Forty studies published prior to February 2016 were identified. The group that received surgery had the lowest incidence of recurrence as 3.0%, followed by the liposuction and laser groups (5.5%, 8.2%, respectively). The liposuction group had the lowest incidence of complications (hematoma, 1.6%; necrosis, 1.5%), followed by the surgery (hematoma, 1.9%; necrosis, 2.1%) and laser groups (hematoma, 3.1%; necrosis, 4.5%). When combining curettage, the recurrence rate was lower in the surgery (P = 0.06) and liposuction groups (P

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Gynecomastia Surgery—Impact on Life Quality: A Prospective Case-Control Study

Objective: To evaluate the results of surgical treatment of gynecomastia in the context of quality of life and satisfaction after the surgery. Methods: Fifty male patients (mean age, 25.1 years [SD = 8 years]) who underwent surgery for gynecomastia and completed both (preoperative and postoperative) stages of the study were included in the analysis. The quality-of-life evaluation instrument was The Short Form-36 Health Survey Questionnaire. Additionally, we used a short questionnaire including 2 questions about patient satisfaction with gynecomastia surgery. Results: The overall change in life satisfaction after gynecomastia surgery was 1 point on Likert scale (sign test, P

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Transverse Infraclavicular Approach to the Thoracoacromial Pedicle for Microsurgical Breast Reconstruction

Background: In microvascular breast reconstruction, the internal mammary and thoracodorsal vessels are commonly used recipients. However, these vessels are sometimes compromised or unavailable. We hypothesize that a transverse infraclavicular (TIC) incision may provide efficient and reliable exposure to perform free flap anastomosis to the thoracoacromial (TAC) vessels for breast reconstruction. Methods: The authors present their results from a cadaveric feasibility study and a retrospective case series of 4 consecutive breast reconstruction patients in which the TIC-TAC approach was used. Results: The cadaveric dissection demonstrated a 5.5-cm pedicle length and a 3.75-mm diameter on the left side. On the right, the pedicle measured 5 cm in length and 4 mm in diameter. The dissection time was 10 minutes on the left side and 13 minutes on the right side. Five free flap breast reconstructions were performed in 4 patients using the TIC approach to the TAC artery which served as the primary recipient. The average pedicle length was 6.25 cm with a diameter of 3.55 mm. The pedicle was isolated and delivered through the infraclavicular incision in an average of 16.3 minutes on the left (n = 2) and 12.6 minutes on the right (n = 3). There were no complications, such as flap compromise or reoperation. Conclusions: The TIC-TAC approach is feasible for microvascular breast reconstruction and can be considered for use by microvascular breast surgeons.

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STARplasty for Reconstruction of the Burned Axilla

Background: Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures. Methods: A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected. Results: Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38–63) and average burn size was 35% (R 18–80). Average time from initial injury to primary reconstruction was 11.1 months (R 3–54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure. Conclusions: Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.

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Intraoperative Assessment of Facial Nerve Trunk Width in Early Childhood With Cervicofacial Lymphatic Malformation

Background: Facial nerve damage during head and neck surgery has long been an important issue. However, few publications on the gross anatomy of the facial nerve are available in the young population. The aim of this study was to provide in vivo measurements of the facial nerve trunk during lymphatic malformation (LM) resection and to determine the association between the trunk width and patient- and disease-related variables. Methods: We conducted a retrospective analysis of 11 consecutive pediatric patients (11 facial nerve trunks) who underwent cervicofacial LM resection. The facial nerve of the affected side was dissected, and its trunk width at bifurcation was measured using calipers under a microscope during the operation. Results: Eleven patients younger than 6 years were enrolled. The median width of the facial nerve in patients younger than 1 year was 1.15 mm; it was 2.5 mm in those older than 1 year. Trunk width was significantly greater in patients older than 1 year than those younger than 1 year, whereas no statistical significance was found when comparing other age groups. Patient weight was positively correlated with trunk width, whereas LM grade and diameter showed no significant correlation. Conclusions: The significantly greater width of the facial nerve trunk in LM patients older than 1 year than those younger than 1 year suggests that the age of 1 may be a threshold for facial nerve hypertrophy and growth acceleration. This study provides informative in vivo data to help understand facial nerve characteristics in young patients.

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Treatment of Advanced Kienböck Disease With a Vascularized Radial Bone Flap Wrapped in the Pronator Quadratus

Purpose: In the present study, we aimed to assess the radiologic and clinical outcomes after excision of the lunate, insertion of a vascularized radial bone flap wrapped in the pronator quadratus, and distraction with an external fixator of the joint, for the treatment of avascular necrosis of the lunate with carpal height collapse, fragmentation, and perilunar osteoarthritic changes. Materials and Methods: From May 2006 to July 2014, a total of 25 patients (13 men and 12 women; mean age, 38.7 years; age range, 28–52 years) with advanced Kienböck disease were treated with excision of the lunate and insertion of a vascularized radial bone flap wrapped in the pronator quadratus, followed by distraction with an external fixator of the joint; all these patients met our inclusion criteria, including symptomatic avascular necrosis of the lunate with carpal collapse and osteoarthritis of the wrist. We evaluated the scaphocapitate angle for radiologic assessment. Moreover, the overall clinical results were graded by using the wrist range of motion, modified Mayo wrist score, and disabilities of the arm, shoulder, and hand score. Results: All the patients exhibited improved symptoms, and subsequently returned to their work and recreational activities. The mean scaphocapitate angles and carpal height ratio improved from 33.7 degrees (range, 32.1–35.7 degrees) and 0.46 degrees (range, 0.42–0.51 degrees) preoperatively to 56.3 degrees (range, 54.7–59.8 degrees) and 0.50 degrees (range, 0.46–0.56 degrees) at the follow-up, respectively. The final average range of motion was as follows: wrist flexion, 73 degrees (range, 62–81 degrees); and extension, 76 degrees (range, 69–88 degrees). The average postoperative modified Mayo wrist score and disabilities of the arm, shoulder, and hand score were 91 points (range, 80–100 points) and 11 points (range, 2–24 points), respectively. Conclusion: We suggest that the excision of the lunate and insertion of a vascularized radial bone flap wrapped in the pronator quadratus, followed by distraction with an external fixator of the joint, is a reliable method for the treatment of Kienböck disease with collapse or fragmentation of the lunate, and achieves high functional scores, increased range of movement, and relief of pain, without any complications.

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The Dawn of Transparency: Insights from the Physician Payment Sunshine Act in Plastic Surgery

Background: The Physician Payments Sunshine Act (PSSA) is a government initiative that requires all biomedical companies to publicly disclose payments to physicians through the Open Payments Program (OPP). The goal of this study was to use the OPP database and evaluate all nonresearch-related financial transactions between plastic surgeons and biomedical companies. Methods: Using the first wave of OPP data published on September 30, 2014, we studied the national distribution of industry payments made to plastic surgeons during a 5-month period. We explored whether a plastic surgeon's scientific productivity (as determined by their h-index), practice setting (private versus academic), geographic location, and subspecialty were associated with payment amount. Results: Plastic surgeons (N = 4195) received a total of US $5,278,613. The median (IQR) payment to a plastic surgeon was US $115 (US $35–298); mean, US $158. The largest payment to an individual was US $341,384. The largest payment category was non-CEP speaker fees (US $1,709,930) followed by consulting fees (US $1,403,770). Plastic surgeons in private practice received higher payments per surgeon compared with surgeons in academic practice (median [IQR], US $165 [US $81–$441] vs median [IQR], US $112 [US $33–$291], rank-sum P

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Ectropion in Facial Tissue Expansion in the Pediatric Population: Incidence, Risk Factors, and Treatment Options

Background: Despite advances in the field of tissue expansion, the face is especially difficult to reconstruct using this technique due to its dynamic nature and high incidence of distortional scarring. This article aimed to review complications seen in pediatric facial tissue expansion, specifically ectropion, as well as its restorative treatment. Methods: A retrospective chart review of pediatric patients treated by tissue expansion for congenital facial lesions, trauma, or burns at Children's Hospital Los Angeles from January 2000 to present was performed. Patients were analyzed for preoperative diagnosis, reconstruction area, tissue expander location, number and fill volume of expanders, incidence of complications, including ectropion, and type of revision surgery. Results: A total of 88 patients with 150 expander reconstructions were examined. The total complication rate was 43.1% with an 11.3% rate of ectropion. Of the 10 cases of ectropion, 9 were treated with canthoplasty, whereas 1 was managed conservatively. In addition to canthoplasty, full-thickness skin graft was preformed in 1 patient, Z-plasty in 1, and lid switch in 2. Discussion: Tissue expansion is a safe and effective method of reconstruction for facial defects in the pediatric population despite complication rates being higher than other areas of the body. Specifically, ectropion can be a devastating complication, often requiring surgical correction. As such, careful planning should go into orientation and design of the reconstruction, and staged procedures should be strongly considered. Additionally, and possibly the most important, is setting patient and parental expectation about the possibility of ectropion and the necessity often for multiple corrective surgeries.

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Ear Aesthetics: Investigation by the Use of an Online Viral Survey

Introduction: The ear is a key facial feature and yet few studies have previously assessed ear aesthetics. This study aimed to assess the anatomical components of the ear that have the greatest impact on the perception of ear aesthetics. Materials and Methods: Three photographs of a male adult ear (close-up, lateral, posterior) were digitally manipulated such that in each, 1 anatomical element of the ear was either enlarged or reduced. A complete set of 16 photographs including a repeat of the original ear as a control were randomized and entered into an online survey that required respondents to rate the attractiveness of each ear on a scale of 1 (least attractive) to 10 (most attractive). The survey was disseminated using email and social media. Results: A total of 248 responses were received, 155 women and 92 men. Respondents were grouped by demographics of age and occupation. Reducing (R) or enlarging (E) the helix (R, P = 0.0256; E, P = 0.003), concha (R, P = 0.0002; E, P =

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Class 3 semaphorins are transcriptionally regulated by 1,25(OH)2D3 in osteoblasts

Publication date: Available online 9 February 2017
Source:The Journal of Steroid Biochemistry and Molecular Biology
Author(s): Jussi Ryynänen, Carsten Kriebitzsch, Mark B. Meyer, Iris Janssens, J. Wesley Pike, Lieve Verlinden, Annemieke Verstuyf
The vitamin D endocrine system is essential for calcium metabolism and skeletal integrity. 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] regulates bone mineral homeostasis and acts directly on osteoblasts. In the present study we characterized the transcriptional regulation of the class 3 semaphorin (Sema3) gene family by 1,25(OH)2D3 in osteoblastic cells. Class 3 semaphorins are secreted proteins that regulate cell growth, morphology and migration, and were recently shown to be involved in bone homeostasis. In ST2, MC3T3-E1 and primary calvarial osteoblast cell cultures we found that all members of the Sema3 gene family were expressed, and that Sema3e and Sema3f were the most strongly induced 1,25(OH)2D3 target genes among the studied cell types. In addition, transcription of Sema3b and Sema3c was upregulated, whereas Sema3d and Sema3g was downregulated by 1,25(OH)2D3 in different osteoblastic cells. Chromatin immunoprecipitation analysis linked to DNA sequencing (ChIP-seq analysis) revealed the presence of the vitamin D receptor at multiple genomic loci in the proximity of Sema3 genes, demonstrating that the genes are primary 1,25(OH)2D3 targets. Furthermore, we showed that recombinant SEMA3E and SEMA3F protein were able to inhibit osteoblast proliferation. However, recombinant SEMA3s did not affect ST2 cell migration. The expression of class 3 semaphorins in osteoblasts together with their regulation by 1,25(OH)2D3 suggests that these genes, involved in the regulation of bone homeostasis, are additional mediators for 1,25(OH)2D3 signaling in osteoblasts.

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Genetics in OtolRhinoLaryngology