Death certificate only proportions should be age adjusted in studies comparing cancer survival across populations and over time

Publication date: January 2016
Source:European Journal of Cancer, Volume 52
Author(s): Hermann Brenner, Felipe A. Castro, Andrea Eberle, Katharina Emrich, Bernd Holleczek, Alexander Katalinic, Lina Jansen
BackgroundThe proportion of cases notified by death certificate only (DCO) is a commonly used data quality indicator in studies comparing cancer survival across regions and over time. We aimed to assess dependence of DCO proportions on the age structure of cancer patients.MethodsUsing data from a national cancer survival study in Germany, we determined age specific and overall (crude) DCO proportions for 24 common forms of cancer. We then derived overall (crude) DCO proportions expected in case of shifts of the age distribution of the cancer populations by 5 and 10 years, respectively, assuming age specific DCO proportions to remain constant.ResultsMedian DCO proportions across the 24 cancers were 2.4, 3.7, 5.5, 8.5 and 23.9% in age groups 15–44, 45–54, 55–64, 65–74, and 75+, respectively. A decrease of ages by 5 and 10 years resulted in decreases of cancer specific crude DCO proportions ranging from 0.4 to 4.8 and from 0.7 to 8.6 percent units, respectively. Conversely, an increase of ages by 5 and 10 years led to increases of cancer specific crude DCO proportions ranging from 0.8 to 4.8 and from 1.8 to 9.6 percent units, respectively. These changes were of similar magnitude (but in opposite direction) as changes in crude 5-year relative survival resulting from the same shifts in age distribution.ConclusionsThe age structure of cancer patient populations has a substantial impact on DCO proportions. DCO proportions should therefore be age adjusted in comparative studies on cancer survival across regions and over time.



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Targeting the Janus-activated kinase-2-STAT3 signalling pathway in pancreatic cancer using the HSP90 inhibitor ganetespib

Publication date: January 2016
Source:European Journal of Cancer, Volume 52
Author(s): Ganji Purnachandra Nagaraju, Anya Mezina, Walid L. Shaib, Jerome Landry, Bassel F. El-Rayes
BackgroundPancreatic cancer (PC) is an aggressive malignancy characterised by chemoresistance. HSP90 is important for stabilisation of proteins, cell signalling and malignant growth. We hypothesised that ganetespib, an HSP90 inhibitor, can inhibit PC cell growth by interfering with multiple signalling cascades, including the Janus-activated kinase (JAK)-STAT pathway, and act synergistically with chemotherapeutic drugs.MethodsThe effects of ganetespib were evaluated in ASPC-1, HPAC, MIA PaCA-2 and PANC-1 cell lines using a cell proliferation assay. Effects on the expression of phosphoinositide 3-kinase (PI3K)/AKT, mitogen-activated protein kinase (MAPK) and JAK-STAT pathways were examined by Western blot. JAK2 and STAT3 were knocked down by transient transfection with JAK2 or STAT3 small interfering RNA. ASPC-1 and HPAC cell lines were tested for sensitivity to ganetespib, 5-fluorouracil/oxaliplatin, and gemcitabine/paclitaxel, alone and in combination, using an in vivo tumour xenograft model.ResultsGanetespib significantly decreased cell proliferation in all tested PC cell lines. Ganetespib decreased the activation of extracellular signal-related kinase (ERK), PI3K/AKT, and c-Jun NH2-terminal kinase (JNK) signalling molecules and diminished the activation of STAT3 in an additive manner with isolated downregulation of JAK2 expression. In animal models, ganetespib potentiated the effects of 5-fluouracil/oxaliplatin and gemcitabine/paclitaxel, as measured by tumour volume. Western blot analysis from tumours removed from animals confirmed the effects of ganetespib on PI3K/AKT, ERK and JNK pathways.ConclusionsGanetespib inhibits the growth of PC cells, an effect associated with downregulation of signalling through the JAK2-STAT3, PI3K/AKT and MAPK pathways. This provides preclinical proof-of-principle that ganetespib enhances the activity of chemotherapeutic agents and warrants further evaluation in PC clinical trials.



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Perpendicular Strut Injection of Hyaluronic Acid Filler for Deep Wrinkles

Summary: Although various injection techniques of hyaluronic acid (HA) filler for facial rejuvenation have been developed, correction of deep wrinkles/grooves, such as the nasolabial fold (NLF), with intradermal or subdermal injections remains difficult. We tested the intradermal HA injection method to place multiple HA struts by (1) inserting a small needle perpendicularly to the wrinkle and (2) injecting HA as intradermal struts with the skin fully stretched by the practitioner's fingers. The results of both NLFs in 10 patients suggest that this technique improves NLFs and maintain the effects more consistently than conventional techniques, although the effects of both methods were almost lost after 6 months. Selective and/or combined application of this technique may enhance the current approach to facial rejuvenation with dermal fillers.

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Incidence of Seromas and Infections Using Fenestrated versus Nonfenestrated Acellular Dermal Matrix in Breast Reconstructions

Background: Acellular dermal matrices (ADMs) provide clinical benefits in breast reconstruction but have been associated with increased postoperative complications, most frequently seromas. Fenestration of the ADM before insertion into the reconstructed breast may reduce the incidence of postoperative complications. In this retrospective analysis, postoperative complications were assessed after breast reconstruction with or without fenestrated ADMs. Methods: Patients who underwent immediate 2-staged implant breast reconstructions using ADM at a single center were assessed. The number of reconstructed breasts was stratified by ADM fenestration status and ADM type. The incidence of seroma, infection, extrusion, and explantation, and cosmetic score, was compared within the 2 stratified groups. A multivariable regression was performed to identify independent risk factors associated with these complications and aesthetic outcome. Results: In total, data from 450 patients who had 603 breast reconstructions using either AlloDerm or FlexHD demonstrated a significantly higher incidence of seroma with nonfenestrated ADMs (20%) versus fenestrated ADMs (11%; P = 0.0098). Rates of infection and explantation, and cosmetic score, were not influenced by fenestration status. In the multivariable analysis, ADM fenestration remained a significant protective factor for seroma formation. FlexHD also yielded a lower incidence of extrusion (P = 0.0031) and a higher cosmetic score (P = 0.0466) compared with AlloDerm after adjusting for other risk factors. Conclusions: The results of this study support ADM fenestration for reduction of seroma incidence in breast reconstruction, without affecting cosmetic results. Additionally, the choice of ADM may reduce extrusion incidence and improve aesthetic outcomes.

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Asian Breast Augmentation: A Systematic Review

Background: Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature. Methods: A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized. Results: Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series. Conclusions: Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.

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Total Columella Reconstruction Using Nasocheek Flap and Septal Cartilage Graft

Summary: The use of the nasocheek sulcus flap with a cartilage strut provides an aesthetically pleasing result in total columella reconstruction. This provides thin hairless skin appropriate for the subunit. Mohs surgery aids in limiting the excision to the tumor involved area, providing a complete clearance and conserving precious units, which have an impact on the reconstructive options. The method of reconstruction described here is simple and easily reproducible, providing an optimal result with almost no donor site morbidity.

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Delphi Study Consensus Recommendations: Patient Selection and Preoperative Planning Measurements for Natrelle 410

Background: There is considerable variation in the planning and implementation process for breast augmentation. Although general guidelines are available, the distinctive characteristics of the Natrelle 410 breast implant warrant surgical guidelines specific to this device. This study aimed to develop consensus recommendations for patient selection and preoperative planning for Natrelle 410 in primary breast augmentation. Methods: Surgeons were invited to participate in this study, which used a modified Delphi method. Participants completed 2 rounds of online surveys, with the second round (Recommendations Survey) based on responses from the first round. Respondents also listed their top priorities for using Natrelle 410 implants. Results: Participants (n = 22) reached consensus on 15 of 18 criteria for patient selection; tuberous breasts, patient preference regarding upper pole shape, and asymmetry of the breasts were the top 3 patient characteristics considered appropriate for the use of Natrelle 410. Consensus was reached on 38 of 51 items related to preoperative planning, with 8 measurements and 6 markings recommended by the participants. Patient-desired outcome was considered the most essential element for Natrelle 410 implant selection; quality of skin envelope and height and width dimension of the breast were selected as the most essential elements for Natrelle 410 implant volume selection. Conclusions: The modified Delphi method resulted in consensus recommendations for patient selection and preoperative planning in primary breast augmentation with the Natrelle 410 breast implant. These recommendations and priorities, used in concert with a surgeon's clinical experience, are designed to optimize surgical outcomes.

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The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery

Summary: Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

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Persistent Pain and Sensory Abnormalities after Abdominoplasty

Background: Persistent postsurgical pain is a well-recognized problem after a number of common surgical procedures, such as amputation, thoracotomy, and inguinal hernia repair. Less is known about persistent pain after cosmetic surgical procedures. We, therefore, decided to study the incidence and characteristics of persistent pain after abdominoplasty, which is one of the most frequent cosmetic surgical procedures. Methods: In September 2014, a link to a web-based questionnaire was mailed to 217 patients who had undergone abdominoplasty between 2006 and 2014 at the Department of Plastic Surgery, Aalborg University Hospital, Denmark. The questionnaire included questions about pain and sensory abnormalities located to the abdominal skin, and physical and psychological function; patient satisfaction with surgery was rated on a 4-point scale. Results: One hundred seventy patients answered the questionnaire. Fourteen patients (8.2%) reported pain within the past 7 days related to the abdominoplasty. Abnormal abdominal skin sensation was common and reported by 138 patients (81%). Sensory hypersensitivity was associated with the presence of persistent pain. Satisfaction with the procedure was reported by 149 (88%) patients. The majority of patients reported improvement on all physical and psychological factors. Patients with pain were more often disappointed with the surgery and unwilling to recommend the surgery. Conclusions: Overall, patients were satisfied with the procedure, although abnormal abdominal skin sensation was common. However, there is a risk of developing persistent neuropathic pain after abdominoplasty, and patients should be informed about this before surgery.

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Delphi Consensus Recommendations: Intraoperative Technique and Postoperative Management of Patients with Natrelle 410 Implants

Background: Anatomically shaped, form-stable Natrelle 410 breast implants were approved in Europe in 1993 and in the United States in 2013. Although general guidelines for breast augmentation are available, the distinctive characteristics of Natrelle 410 warrant specific guidelines for this device. The goal of this study was to generate consensus recommendations for intraoperative technique and postoperative management with Natrelle 410 in primary breast augmentation. Methods: Surgeons were invited to participate in the study, which used a modified Delphi method. Participants completed 2 rounds of online surveys; the second survey (Recommendations Survey) was generated based on first survey results. Respondents also listed top priorities for use of Natrelle 410. Results: Participants (n = 22) reached consensus on 15 of 18 perioperative and surgical techniques; dual-plane placement, tight pockets, and limiting the boundaries of dissection were among intraoperative techniques considered most important for Natrelle 410. Consensus was reached for 18 of 32 items regarding postoperative management and 6 of 9 open-ended postoperative activity restrictions. Consensus on activity restrictions with specified time limits were similar to consensus recommendations on general restrictions. Top participant-identified intraoperative and postoperative management practices for Natrelle 410 were dual-plane placement of the implant and wearing a bra postoperatively, respectively. Conclusions: The Delphi method identified consensus recommendations on a broad range of intraoperative techniques and postoperative management practices for primary breast augmentation with Natrelle 410. These recommendations and priorities provide surgeons with a framework that, together with the surgeon's experience, will contribute to optimal clinical outcomes with Natrelle 410.

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A Practical Surgical Technique to Expose the Mental Nerve in Narrowing Genioplasty

Summary: In this article, the authors present a practical surgical technique using the anatomical character of the inferior alveolar nerve to fully expose the mental nerve (MN) in narrowing genioplasty. During the procedure, a rectangular mandibular outer cortex adjacent to the mental foramen is removed before the osteotomy. The objective is to avoid the injury of the MN from the reciprocating saw or bur and offer abundant space for the surgical operation. The technique has a minimal learning curve and will be useful to plastic surgeons to minimize unintentional cutting or pulling injury to the MN in narrowing genioplasty.

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EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model

Hepatic venous pressure gradient (HVPG) currently serves as a surrogate for portal pressure measurement but has many limitations. We have developed a novel technique for rapid and direct portal pressure measurements using a digital pressure wire delivered through an EUS-guided 22-G FNA needle. Our aims were to evaluate (1) short term safety and technical feasibility; (2) procedural duration and subjective workload assessment; and (3) accuracy compared with a transjugular criterion standard approach.

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Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, it is difficult to determine an appropriate resection line using only the laparoscopic approach. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique, by combining laparoscopic gastric resection with endoscopic submucosal dissection, and have used this procedure to resect gastric SMTs. The present study aimed to present this procedure and evaluate the safety and feasibility of this procedure for resecting gastric SMTs.

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Contemporary Management of Acute Type B Dissection

Publication date: Available online 9 December 2015
Source:European Journal of Vascular and Endovascular Surgery
Author(s): A.J. Scott, C.D. Bicknell
ObjectiveGrowing confidence in thoracic endovascular aortic repair (TEVAR) for the management of acute type B aortic dissection has resulted in controversies regarding optimum patient selection and the timing of intervention. In this review a clinical vignette to present a practical perspective on the contemporary management of acute type B dissection (ABAD) in a specialist vascular centre with particular focus on areas of debate is used.MethodsThis is a narrative clinical review.ResultsAggressive anti-impulse therapy is the cornerstone of management of all patients with ABAD. However, 20–30% of patients develop complicated ABAD defined by the presence of malperfusion syndromes, acute aortic dilatation, dissection extension, or persistent pain and hypotension. These complicated patients typically require intervention, and non-randomised series suggest TEVAR to be an effective alternative to open repair with a lower morbidity. There is considerable interest and controversy surrounding the use of TEVAR in uncomplicated ABAD patients for whom the intervention-free survival at 6 years is less than 50% for patients managed with anti-impulse therapy. Data regarding this question are sparse, but two randomised trials (ADSORB and INSTEAD) both demonstrated a higher rate of favourable aortic remodelling in patients managed with TEVAR than medical therapy alone. However, it is unclear whether this positive remodelling translates into a reduction in long-term mortality sufficient to balance the early perioperative hazards of endografting.ConclusionDespite increasing adeptness at endovascular stenting, the long-term outcomes of patients with ABAD leave significant room for improvement. In particular, the optimum management of patients with uncomplicated disease is unclear and guidance from trials powered for long-term mortality is awaited. Until then, the principals of management of ABAD remain aggressive medical therapy for all patients, with TEVAR primarily reserved for those who develop complications.



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Death certificate only proportions should be age adjusted in studies comparing cancer survival across populations and over time

Publication date: January 2016
Source:European Journal of Cancer, Volume 52
Author(s): Hermann Brenner, Felipe A. Castro, Andrea Eberle, Katharina Emrich, Bernd Holleczek, Alexander Katalinic, Lina Jansen
BackgroundThe proportion of cases notified by death certificate only (DCO) is a commonly used data quality indicator in studies comparing cancer survival across regions and over time. We aimed to assess dependence of DCO proportions on the age structure of cancer patients.MethodsUsing data from a national cancer survival study in Germany, we determined age specific and overall (crude) DCO proportions for 24 common forms of cancer. We then derived overall (crude) DCO proportions expected in case of shifts of the age distribution of the cancer populations by 5 and 10 years, respectively, assuming age specific DCO proportions to remain constant.ResultsMedian DCO proportions across the 24 cancers were 2.4, 3.7, 5.5, 8.5 and 23.9% in age groups 15–44, 45–54, 55–64, 65–74, and 75+, respectively. A decrease of ages by 5 and 10 years resulted in decreases of cancer specific crude DCO proportions ranging from 0.4 to 4.8 and from 0.7 to 8.6 percent units, respectively. Conversely, an increase of ages by 5 and 10 years led to increases of cancer specific crude DCO proportions ranging from 0.8 to 4.8 and from 1.8 to 9.6 percent units, respectively. These changes were of similar magnitude (but in opposite direction) as changes in crude 5-year relative survival resulting from the same shifts in age distribution.ConclusionsThe age structure of cancer patient populations has a substantial impact on DCO proportions. DCO proportions should therefore be age adjusted in comparative studies on cancer survival across regions and over time.



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Targeting the Janus-activated kinase-2-STAT3 signalling pathway in pancreatic cancer using the HSP90 inhibitor ganetespib

Publication date: January 2016
Source:European Journal of Cancer, Volume 52
Author(s): Ganji Purnachandra Nagaraju, Anya Mezina, Walid L. Shaib, Jerome Landry, Bassel F. El-Rayes
BackgroundPancreatic cancer (PC) is an aggressive malignancy characterised by chemoresistance. HSP90 is important for stabilisation of proteins, cell signalling and malignant growth. We hypothesised that ganetespib, an HSP90 inhibitor, can inhibit PC cell growth by interfering with multiple signalling cascades, including the Janus-activated kinase (JAK)-STAT pathway, and act synergistically with chemotherapeutic drugs.MethodsThe effects of ganetespib were evaluated in ASPC-1, HPAC, MIA PaCA-2 and PANC-1 cell lines using a cell proliferation assay. Effects on the expression of phosphoinositide 3-kinase (PI3K)/AKT, mitogen-activated protein kinase (MAPK) and JAK-STAT pathways were examined by Western blot. JAK2 and STAT3 were knocked down by transient transfection with JAK2 or STAT3 small interfering RNA. ASPC-1 and HPAC cell lines were tested for sensitivity to ganetespib, 5-fluorouracil/oxaliplatin, and gemcitabine/paclitaxel, alone and in combination, using an in vivo tumour xenograft model.ResultsGanetespib significantly decreased cell proliferation in all tested PC cell lines. Ganetespib decreased the activation of extracellular signal-related kinase (ERK), PI3K/AKT, and c-Jun NH2-terminal kinase (JNK) signalling molecules and diminished the activation of STAT3 in an additive manner with isolated downregulation of JAK2 expression. In animal models, ganetespib potentiated the effects of 5-fluouracil/oxaliplatin and gemcitabine/paclitaxel, as measured by tumour volume. Western blot analysis from tumours removed from animals confirmed the effects of ganetespib on PI3K/AKT, ERK and JNK pathways.ConclusionsGanetespib inhibits the growth of PC cells, an effect associated with downregulation of signalling through the JAK2-STAT3, PI3K/AKT and MAPK pathways. This provides preclinical proof-of-principle that ganetespib enhances the activity of chemotherapeutic agents and warrants further evaluation in PC clinical trials.



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Perpendicular Strut Injection of Hyaluronic Acid Filler for Deep Wrinkles

Summary: Although various injection techniques of hyaluronic acid (HA) filler for facial rejuvenation have been developed, correction of deep wrinkles/grooves, such as the nasolabial fold (NLF), with intradermal or subdermal injections remains difficult. We tested the intradermal HA injection method to place multiple HA struts by (1) inserting a small needle perpendicularly to the wrinkle and (2) injecting HA as intradermal struts with the skin fully stretched by the practitioner's fingers. The results of both NLFs in 10 patients suggest that this technique improves NLFs and maintain the effects more consistently than conventional techniques, although the effects of both methods were almost lost after 6 months. Selective and/or combined application of this technique may enhance the current approach to facial rejuvenation with dermal fillers.

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Incidence of Seromas and Infections Using Fenestrated versus Nonfenestrated Acellular Dermal Matrix in Breast Reconstructions

Background: Acellular dermal matrices (ADMs) provide clinical benefits in breast reconstruction but have been associated with increased postoperative complications, most frequently seromas. Fenestration of the ADM before insertion into the reconstructed breast may reduce the incidence of postoperative complications. In this retrospective analysis, postoperative complications were assessed after breast reconstruction with or without fenestrated ADMs. Methods: Patients who underwent immediate 2-staged implant breast reconstructions using ADM at a single center were assessed. The number of reconstructed breasts was stratified by ADM fenestration status and ADM type. The incidence of seroma, infection, extrusion, and explantation, and cosmetic score, was compared within the 2 stratified groups. A multivariable regression was performed to identify independent risk factors associated with these complications and aesthetic outcome. Results: In total, data from 450 patients who had 603 breast reconstructions using either AlloDerm or FlexHD demonstrated a significantly higher incidence of seroma with nonfenestrated ADMs (20%) versus fenestrated ADMs (11%; P = 0.0098). Rates of infection and explantation, and cosmetic score, were not influenced by fenestration status. In the multivariable analysis, ADM fenestration remained a significant protective factor for seroma formation. FlexHD also yielded a lower incidence of extrusion (P = 0.0031) and a higher cosmetic score (P = 0.0466) compared with AlloDerm after adjusting for other risk factors. Conclusions: The results of this study support ADM fenestration for reduction of seroma incidence in breast reconstruction, without affecting cosmetic results. Additionally, the choice of ADM may reduce extrusion incidence and improve aesthetic outcomes.

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Asian Breast Augmentation: A Systematic Review

Background: Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature. Methods: A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized. Results: Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series. Conclusions: Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.

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Total Columella Reconstruction Using Nasocheek Flap and Septal Cartilage Graft

Summary: The use of the nasocheek sulcus flap with a cartilage strut provides an aesthetically pleasing result in total columella reconstruction. This provides thin hairless skin appropriate for the subunit. Mohs surgery aids in limiting the excision to the tumor involved area, providing a complete clearance and conserving precious units, which have an impact on the reconstructive options. The method of reconstruction described here is simple and easily reproducible, providing an optimal result with almost no donor site morbidity.

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Delphi Study Consensus Recommendations: Patient Selection and Preoperative Planning Measurements for Natrelle 410

Background: There is considerable variation in the planning and implementation process for breast augmentation. Although general guidelines are available, the distinctive characteristics of the Natrelle 410 breast implant warrant surgical guidelines specific to this device. This study aimed to develop consensus recommendations for patient selection and preoperative planning for Natrelle 410 in primary breast augmentation. Methods: Surgeons were invited to participate in this study, which used a modified Delphi method. Participants completed 2 rounds of online surveys, with the second round (Recommendations Survey) based on responses from the first round. Respondents also listed their top priorities for using Natrelle 410 implants. Results: Participants (n = 22) reached consensus on 15 of 18 criteria for patient selection; tuberous breasts, patient preference regarding upper pole shape, and asymmetry of the breasts were the top 3 patient characteristics considered appropriate for the use of Natrelle 410. Consensus was reached on 38 of 51 items related to preoperative planning, with 8 measurements and 6 markings recommended by the participants. Patient-desired outcome was considered the most essential element for Natrelle 410 implant selection; quality of skin envelope and height and width dimension of the breast were selected as the most essential elements for Natrelle 410 implant volume selection. Conclusions: The modified Delphi method resulted in consensus recommendations for patient selection and preoperative planning in primary breast augmentation with the Natrelle 410 breast implant. These recommendations and priorities, used in concert with a surgeon's clinical experience, are designed to optimize surgical outcomes.

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The Importance of Hand Appearance as a Patient-Reported Outcome in Hand Surgery

Summary: Hand appearance is meaningful to patients because hands are an essential part of human interactions, communication, and social integration. Recent literature indicates that hand aesthetics is an important, measurable patient-reported outcome. In hand surgery, several outcome instruments exist that accurately measure functional outcomes, but aesthetics is often overlooked or imprecisely measured. This makes comparison of disease burden and effectiveness of therapies, as they pertain to aesthetics, difficult. This special topic article outlines the aesthetic features of the hand, how literature is evaluating the appearance of the hand in outcomes research, and proposes a novel approach to assessing hand aesthetics.

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Persistent Pain and Sensory Abnormalities after Abdominoplasty

Background: Persistent postsurgical pain is a well-recognized problem after a number of common surgical procedures, such as amputation, thoracotomy, and inguinal hernia repair. Less is known about persistent pain after cosmetic surgical procedures. We, therefore, decided to study the incidence and characteristics of persistent pain after abdominoplasty, which is one of the most frequent cosmetic surgical procedures. Methods: In September 2014, a link to a web-based questionnaire was mailed to 217 patients who had undergone abdominoplasty between 2006 and 2014 at the Department of Plastic Surgery, Aalborg University Hospital, Denmark. The questionnaire included questions about pain and sensory abnormalities located to the abdominal skin, and physical and psychological function; patient satisfaction with surgery was rated on a 4-point scale. Results: One hundred seventy patients answered the questionnaire. Fourteen patients (8.2%) reported pain within the past 7 days related to the abdominoplasty. Abnormal abdominal skin sensation was common and reported by 138 patients (81%). Sensory hypersensitivity was associated with the presence of persistent pain. Satisfaction with the procedure was reported by 149 (88%) patients. The majority of patients reported improvement on all physical and psychological factors. Patients with pain were more often disappointed with the surgery and unwilling to recommend the surgery. Conclusions: Overall, patients were satisfied with the procedure, although abnormal abdominal skin sensation was common. However, there is a risk of developing persistent neuropathic pain after abdominoplasty, and patients should be informed about this before surgery.

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Delphi Consensus Recommendations: Intraoperative Technique and Postoperative Management of Patients with Natrelle 410 Implants

Background: Anatomically shaped, form-stable Natrelle 410 breast implants were approved in Europe in 1993 and in the United States in 2013. Although general guidelines for breast augmentation are available, the distinctive characteristics of Natrelle 410 warrant specific guidelines for this device. The goal of this study was to generate consensus recommendations for intraoperative technique and postoperative management with Natrelle 410 in primary breast augmentation. Methods: Surgeons were invited to participate in the study, which used a modified Delphi method. Participants completed 2 rounds of online surveys; the second survey (Recommendations Survey) was generated based on first survey results. Respondents also listed top priorities for use of Natrelle 410. Results: Participants (n = 22) reached consensus on 15 of 18 perioperative and surgical techniques; dual-plane placement, tight pockets, and limiting the boundaries of dissection were among intraoperative techniques considered most important for Natrelle 410. Consensus was reached for 18 of 32 items regarding postoperative management and 6 of 9 open-ended postoperative activity restrictions. Consensus on activity restrictions with specified time limits were similar to consensus recommendations on general restrictions. Top participant-identified intraoperative and postoperative management practices for Natrelle 410 were dual-plane placement of the implant and wearing a bra postoperatively, respectively. Conclusions: The Delphi method identified consensus recommendations on a broad range of intraoperative techniques and postoperative management practices for primary breast augmentation with Natrelle 410. These recommendations and priorities provide surgeons with a framework that, together with the surgeon's experience, will contribute to optimal clinical outcomes with Natrelle 410.

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A Practical Surgical Technique to Expose the Mental Nerve in Narrowing Genioplasty

Summary: In this article, the authors present a practical surgical technique using the anatomical character of the inferior alveolar nerve to fully expose the mental nerve (MN) in narrowing genioplasty. During the procedure, a rectangular mandibular outer cortex adjacent to the mental foramen is removed before the osteotomy. The objective is to avoid the injury of the MN from the reciprocating saw or bur and offer abundant space for the surgical operation. The technique has a minimal learning curve and will be useful to plastic surgeons to minimize unintentional cutting or pulling injury to the MN in narrowing genioplasty.

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Forequarter Amputation and Immediate Reconstruction with a Free Extended Humeral-Radial Forearm Flap

A forequarter amputation is a radical ablative surgical procedure that includes the entire upper extremity with its shoulder girdle. We present a 53-year-old woman with a solid slow growing tumor in her right shoulder of 15 x 20 cm in diameter. Resection and immediate reconstruction with a free radial forearm flap extended from the distal third of the arm to the midpalmar region, taking the humeral artery and the cephalic vein as a main peddicle. The final outcome is shown at six weeks after the surgery.

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Long-term Patency of Primary Arterial Repair and the Modified Cold Intolerance Symptom Severity Questionnaire

Background: The goal of this study was to assess the long-term arterial patency of repaired arteries in the upper extremity and any morbidity resulting from the subsequent occlusion of these vessels. Concurrently, a new questionnaire, the modified Cold Intolerance Symptom Severity (mod CISS) questionnaire, was developed to allow for better assessment of cold intolerance. Methods: Thirteen patients who had undergone repair of the radial (4 patients), ulnar (6 patients), brachial (1 patient), digital (1), and an undefined lower arm artery (1) were examined using questionnaires, physical examination, and high-resolution ultrasound. Results: Outcome measures that were statistically significantly worse in the group of patients who presented with nerve injuries included cold intolerance symptoms, Disabilities of the Arm, Shoulder, and Hand score, Michigan Hand Questionnaire, and grip strength (middle setting on dynamometer). The results from the mod CISS correlated with high statistical significance with the results of the CISS score for the injured hand. Of note, wrist extension was significantly better with patent arteries. Conclusions: Sixty-seven percent of arterial repairs remained patent at 6 years (mean) follow-up. The presence of nerve injury has a higher impact on the outcome metrics assessed in this study than arterial patency. Our modification of the CISS score enhances its utility as a survey of cold intolerance.

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Evaluation of the Effects of Bile on the Arterial Tonus in a Rabbit Model

Background: Hepatic artery anastomosis is an essential part of live-donor liver transplantation, and during this anastomosis, an unusual contact between bile and vessel ends is observed. In this study, the effects of this nonphysiological contact in a rabbit model were evaluated. Methods: The study was designed in 2 steps—in vitro and in vivo. Three groups were established for the in vitro study. In the first group, vessels were incubated in Krebs solution with 5% bile for 1 minute. In the second group, vessels were kept in Krebs solution with 5% bile for 5 minutes. Vessels in the control group were kept in Krebs solution without bile. All groups were examined for responses to vasodilator and vasoconstrictor agents in organ bath system. The specimens were evaluated immunohistochemically and histopathologically. In the in vivo step, microvascular anastomosis was performed bilaterally. Right carotid artery was anastomosed during bile contamination as study group, and left carotid artery was anastomosed without bile contamination as control group. Blood flow indexes were measured. Results: The results of the in vitro study revealed decreased responses to contractile and relaxing agents in the first study group compared with that of the control group (P 0.05). There was no postoperative spasm in the study group. However, there was significant vasospasm in the control group (P

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Pediatric Stinger Syndrome: Acute Brachial Plexopathy After Minor Trauma

Summary: The "stinger" or "burner" is a form of transient brachial plexopathy termed for its characteristic knife-like pain extending from the neck to the fingertips. Muscle weakness and paresthesia are oftentimes associated symptoms and are similarly temporary. Commonly observed in athletes of contact sports, the stinger results from high force trauma causing either traction/direct compression to the brachial plexus or extension/compression of the cervical nerve roots. We describe a pediatric case of a stinger in a 14-year-old boy, which was caused by a relatively low force trauma accident. Our management strategy and recommendations are discussed.

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LED Light Characteristics for Surgical Shadowless Lamps and Surgical Loupes

Background: Blue light has more energy than longer wavelength light and can penetrate the eye to reach the retina. When surgeons use magnifying loupes under intensive surgical shadowless lamps for better view of the surgical field, the total luminance is about 200 times brighter than that of typical office lighting. In this study, the effects of 2 types of shadowless lamps were compared. Moreover, the effect of various eyeglasses, which support magnifying loupes, on both the light energy and color rendering was considered. Methods: The light intensity and color rendering were measured on 3 variables: light transmittance, light intensity, and color rendering. Results: Under shadowless lamps, the light energy increased with low-magnification loupes and decreased with high-magnification loupes. Filtering eyeglasses reduced the energy, especially in conditions where the low-magnification loupe was used. The best color-rendering index values were obtained with computer eyeglasses under conventional light-emitting diode shadowless lamps and with no glass and with lightly yellow-tinted lenses under less-blue light-emitting diode. Conclusions: Microsurgeons are exposed to strong lighting throughout their career, and proper color rendering must be considered for easier recognition. Light toxicity and loss of color rendering can be reduced with an appropriate combination of shadowless lamps and colored eyeglasses.

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Costal Grafting in Mandibular Reconstruction

Background: Reconstruction of mandibular bone defect is a common indication in craniomaxillofacial surgery, and free fibular flap is the gold standard for this indication. However, there are alternatives; nonvascular bone grafting is one of them, and we present the costal grafting for mandibular reconstruction, a classic technique that is reliable, efficient, and produced less morbidity than the technique of using composite free flaps. Method: A 9-year retrospective review of 54 patients treated surgically for mandibular reconstruction was performed. The criterion mainly analyzed was graft survival. The surgical technique was described in detail. Results: A total of 54 patients with mandibular bone defect were identified. Five symphysis, 46 corpus, and 20 ramus defects were considered. These patients underwent reconstruction by costal grafting, and the engrafting was successful in 92.6% of cases. Dental rehabilitation with dental implants was realized in 70% of cases. Conclusions: The approach described in this article allowed the authors to obtain good results with costal grafting for mandibular reconstruction and dental rehabilitation. Costal grafting is a good alternative for fibula free flap in specific indications. Reconstruction of mandibular bone defect is a common indication in craniomaxillofacial surgery. Since the 1980s, the gold standard for these defects is the use of free fibular flap.1 In some cases, this technique is contradicted; the surgeon then has several possibilities for the use of free osteomyocutaneous flaps (iliac crest, scapula, and serrato-costal flaps).2–8

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The human microbiome, asthma, and allergy

The human microbiome can be defined as the microorganisms that reside within and on our bodies and how they interact with the environment. Recent research suggests that numerous mutually beneficial interactions occur between a human and their microbiome, including those that are essential for good health. Modern microbiological detection techniques have contributed to new knowledge about microorganisms in their human environment. These findings reveal that the microbiomes of the lung and gut contribute to the pathogenesis of asthma and allergy. For example, evidence indicates that the microbiome of the gut regulates the activities of helper T cell subsets (Th1 and Th2) that affect the development of immune tolerance. Moreover, recent studies demonstrate differences between the lung microbiomes of healthy and asthmatic subjects. The hygiene and biodiversity hypotheses explain how exposure to microorganisms is associated with asthma and allergy. Although those living in developed countries are exposed to fewer and less diverse microorganisms compared with the inhabitants of developing countries, they are experiencing an increase in the incidence of asthma and allergies. Detailed analyses of the human microbiome, as are being conducted under the auspices of the Human Microbiome Project initiated in 2007, promise to contribute insights into the mechanisms and factors that cause asthma and allergy that may lead to the development of strategies to prevent and treat these diseases.

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Fluorescence in situ hybridization compared with conventional cytology for the diagnosis of malignant biliary tract strictures in Asian patients

Fluorescence in situ hybridization (FISH) has improved the diagnostic performance of cytology for evaluation of malignant biliary strictures in the US and Europe. The utility of FISH for diagnosis of biliary strictures in Asia is currently unknown. We aimed to compare the sensitivity of FISH and conventional cytology for the diagnosis of malignant biliary strictures in Thai patients.

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Endoscopic Removal of Ingested Nitrile Gloves

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Novel approach to recanalizing an occluded cystic duct after cholecystoduodenostomy by lumen-apposing metal mesh stent for malignant obstructive jaundice

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Modified endoscopic submucosal dissection techniques before endoscopic revision of a gastric bypass

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Endoscopic choledochoduodenostomy and gastrojejunostomy in the treatment of biliary and duodenal obstruction

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Ex-vivo comparison of the lumen-apposing properties of EUS-specific stents (with video)

Several EUS–specific stents have become available. Some of these stents claim lumen-apposing properties but objective data measuring such properties are not available. The aim of this study is to measure the lumen-apposing force (LAF) of these stents.

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EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model

Hepatic venous pressure gradient (HVPG) currently serves as a surrogate for portal pressure measurement but has many limitations. We have developed a novel technique for rapid and direct portal pressure measurements using a digital pressure wire delivered through an EUS-guided 22-G FNA needle. Our aims were to evaluate (1) short term safety and technical feasibility; (2) procedural duration and subjective workload assessment; and (3) accuracy compared with a transjugular criterion standard approach.

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Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, it is difficult to determine an appropriate resection line using only the laparoscopic approach. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique, by combining laparoscopic gastric resection with endoscopic submucosal dissection, and have used this procedure to resect gastric SMTs. The present study aimed to present this procedure and evaluate the safety and feasibility of this procedure for resecting gastric SMTs.

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Effect of sustained release of rhBMP-2 from dried and wet hyaluronic acid hydrogel carriers compared with direct dip coating of rhBMP-2 on peri-implant osteogenesis of dental implants in canine mandibles

Hyaluronic acid (HA) hydrogel has been used as a carrier of recombinant human bone morphogenetic protein (rhBMP)-2 for sustained delivery. To enhance peri-implant osteogenesis, a dried coating of rhBMP-2 HA hydrogel (BMP-HAH) on dental implants was designed; this approach provides the advantage of omitting in situ preparation of wet HA hydrogel. Sustained release of rhBMP-2 was more efficient for dried hydrogel over wet hydrogel. For both types, the released rhBMP-2 consistently led to enhanced alkaline phosphatase activity and osterix expression in human mesenchymal stromal cells.

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The human microbiome, asthma, and allergy

The human microbiome can be defined as the microorganisms that reside within and on our bodies and how they interact with the environment. Recent research suggests that numerous mutually beneficial interactions occur between a human and their microbiome, including those that are essential for good health. Modern microbiological detection techniques have contributed to new knowledge about microorganisms in their human environment. These findings reveal that the microbiomes of the lung and gut contribute to the pathogenesis of asthma and allergy. For example, evidence indicates that the microbiome of the gut regulates the activities of helper T cell subsets (Th1 and Th2) that affect the development of immune tolerance. Moreover, recent studies demonstrate differences between the lung microbiomes of healthy and asthmatic subjects. The hygiene and biodiversity hypotheses explain how exposure to microorganisms is associated with asthma and allergy. Although those living in developed countries are exposed to fewer and less diverse microorganisms compared with the inhabitants of developing countries, they are experiencing an increase in the incidence of asthma and allergies. Detailed analyses of the human microbiome, as are being conducted under the auspices of the Human Microbiome Project initiated in 2007, promise to contribute insights into the mechanisms and factors that cause asthma and allergy that may lead to the development of strategies to prevent and treat these diseases.

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Fluorescence in situ hybridization compared with conventional cytology for the diagnosis of malignant biliary tract strictures in Asian patients

Fluorescence in situ hybridization (FISH) has improved the diagnostic performance of cytology for evaluation of malignant biliary strictures in the US and Europe. The utility of FISH for diagnosis of biliary strictures in Asia is currently unknown. We aimed to compare the sensitivity of FISH and conventional cytology for the diagnosis of malignant biliary strictures in Thai patients.

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Endoscopic Removal of Ingested Nitrile Gloves

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Novel approach to recanalizing an occluded cystic duct after cholecystoduodenostomy by lumen-apposing metal mesh stent for malignant obstructive jaundice

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Modified endoscopic submucosal dissection techniques before endoscopic revision of a gastric bypass

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Endoscopic choledochoduodenostomy and gastrojejunostomy in the treatment of biliary and duodenal obstruction

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Ex-vivo comparison of the lumen-apposing properties of EUS-specific stents (with video)

Several EUS–specific stents have become available. Some of these stents claim lumen-apposing properties but objective data measuring such properties are not available. The aim of this study is to measure the lumen-apposing force (LAF) of these stents.

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EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model

Hepatic venous pressure gradient (HVPG) currently serves as a surrogate for portal pressure measurement but has many limitations. We have developed a novel technique for rapid and direct portal pressure measurements using a digital pressure wire delivered through an EUS-guided 22-G FNA needle. Our aims were to evaluate (1) short term safety and technical feasibility; (2) procedural duration and subjective workload assessment; and (3) accuracy compared with a transjugular criterion standard approach.

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Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, it is difficult to determine an appropriate resection line using only the laparoscopic approach. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique, by combining laparoscopic gastric resection with endoscopic submucosal dissection, and have used this procedure to resect gastric SMTs. The present study aimed to present this procedure and evaluate the safety and feasibility of this procedure for resecting gastric SMTs.

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