Development of thresholds and a visualization tool for use of a blood test in routine clinical dementia practice.

INTRODUCTION: We developed a multimarker blood test result interpretation tool for the clinical dementia practice, including phosphorylated (P-)tau181, amyloid-beta (Abeta)42/40, glial fibrillary acidic protein (GFAP), and neurofilament light (NfL). METHODS: We measured the plasma biomarkers with Simoa (n = 1199), applied LASSO regression for biomarker selection and receiver operating characteristics (ROC) analyses to determine diagnostic accuracy. We validated our findings in two independent cohorts and constructed a visualization approach. RESULTS: P-tau181, GFAP, and NfL were selected. This combination had area under the curve (AUC) = 83% to identify amyloid positivity in pre-dementia stages, AUC = 87%-89% to differentiate Alzheimer's or controls from frontotemporal dementia, AUC = 74%-76% to differentiate Alzheimer's or controls from dementia with Lewy bodies. Highly reproducible AUCs were obtained in independent cohorts. The resulting visualization tool includes UpSet plots to visualize the stand-alone biomarker results and density plots to visualize the biomarker results combined. DISCUSSION: Our multimarker blood test interpretation tool is ready for testing in real-world clinical dementia settings. HIGHLIGHTS: We developed a multimarker blood test interpretation tool for clinical dementia practice. Our interpretation tool includes plasma biomarkers P-tau, GFAP, and NfL. Our tool is particularly useful for Alzheimer's and frontotemporal dementia diagnosis.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Intraoperative Fluorescence Imaging to Identify and Preserve the Fifth Anterior Intercostal Sensory Nerves during Inferior Pedicle Reduction Mammoplasty.

Postoperative sensitivity of the nipple-areola complex (NAC) is an important concern for women after reduction mammoplasty. Previous studies have demonstrated that sensory branches of the fifth anterior intercostal nerve are important for innervating the NAC and that using an inferior pedicle technique is associated with improved sensory retention. The significance of this case report is that it demonstrates the importance of the fifth anterior intercostal sensory nerve branches using a prototype fluorescent imaging camera. The benefit of this device is that it can detect intraoperative auto-fluorescence of nerves and facilitate their identification and preservation, potentially facilitating the retention of sensation in the NAC and surrounding skin. The goals of this article are, therefore, to demonstrate the importance of this neurovascular pedicle when the inferior pedicle technique is used for breast reduction; and to provide demonstrative evidence of the nerve's presence within the fifth anterior intercostal artery perforator pedicle. The case involved a woman with mammary hypertrophy who underwent bilateral reduction mammoplasty using the inferior pedicle technique. Full NAC sensation was demonstrated on postoperative day 3 with complete sensory recovery at 1- and 3-month follow-up confirmed. To our knowledge, this is the first reported instance of the fifth intercostal nerve being visualized during aesthetic breast surgery, demonstrating the importance of this neurovascular bundle for sensory preservation when an inferior pedicle reduction mammaplasty technique is used.

Soft tissue response and determination of underlying risk drivers for recession and mucositis after AMSJI implantation in the maxilla.

PURPOSE: There are few treatment options for oral rehabilitation in patients with advanced maxillary resorption (Cawood-Howell Class V or more). Patient-specific, 3D-printed titanium subperiosteal implants have been described as a potentially valuable alternative solution. Surgeon and patient mediated functional outcomes have been studied and the results are promising. The surrounding soft tissue health has been much less researched. This study aims to evaluate the soft tissue response to the placement of additively manufactured subperiosteal jaw implants (AMSJI®) in the severely atrophic maxilla and to identify possible risk factors for soft tissue breakdown. MATERIALS AND METHODS: An international multicenter study was conducted and fifteen men (mean age 64.62 years, SD ± 6.75) and twenty-five women (mean age 65.24 years, SD ± 6.77) with advanced maxillary jaw resorption (Cawood-Howell Class V or more) were included in this study. General patient data were collected and all subjects were clinically examined. Inclusion criteria were patients who underwent bilateral AMSJI placement® in the maxilla at least a year before and whose surgeon and themselves agreed to participate in the study before their inclusion. RESULTS: A total of forty patients were enrolled with a mean follow-up period of 917 days (SD ± 306.89 days). Primary stability of the implant was achieved postoperatively in all cases, and all implants were loaded with a final prosthesis. At the time of study, only one patient showed mobility of the bilateral AMSJI (more than 1 mm). Exposure of the framework, due to mucosal recession, was seen in 26 patients (65%) and was mainly in the left (21.43%) and right (18.57%) mid-lateral region. Thin biotype and the presence of mucositis were found to be risk factors (p-value < 0.05). Although not significant, smokers had a nearly seven times (Odds ratio 6.88, p=0.08) more risk of developing a recession compared to nonsmokers. CONCLUSION: Twenty-six (65%) patients presented with a recession in one or (more) of the seven regions after oral rehabilitation with bilateral AMSJI installation. Several risk drivers were evaluated. The collapse of soft tissues around the AMSJI that led to caudal exposure of the arms was correlated with a thin biotype and the presence of mucositis.

The ideal shape of the female jaw angle: An online survey.

The aim of this study was to determine the characteristics of an attractive white female jaw angle in the three dimensions. An online survey of photographs of celebrities and laypeople was used to rate their attractiveness using 6 questions and a 3-item Likert scale. If ≥ 80% of participants rated a model as having attractive aesthetic features, it was considered attractive. The following features were considered important: a gonial angle in profile of 125.5° and in anterior view of 142°, an intergonial-interzygomatic width ratio of 0.83 and the vertical position of the jaw angles at the level of the stomion or upper lip. Surgeons can use these consensus criteria to help design a jaw angle implant, define orthognathic surgical strategies, or shape the angle using injectables.

The Anatomy of the Frontalis Muscle Revisited: A Detailed Anatomic, Clinical, and Physiologic Study.

BACKGROUND: There are differing opinions with regard to the specific mechanical forces related to contraction of the frontalis muscle and how it exerts its effects on eyebrow motion. OBJECTIVES: To perform a detailed anatomic and clinical study of the frontalis muscle in cadavers and patients to better define the movement of the frontalis muscle. METHODS: This study consisted of four arms that included: 1) dynamic ecography to evaluate movement of the frontalis muscle, 2) anatomical study of the relationship between the frontalis muscle and the deep fascia, 3) histological study to define the frontalis muscle attachments and 4) clinical study to evaluate the action of the frontalis muscle in patients undergoing a temporal face lift. RESULTS: The frontalis muscle was attached, inserted, and adhered to the deep layer of the fascia in the superior cephalic and middle third of the forehead. In the superior cephalic third of the forehead, loose areolar tissue was observed deep to the frontalis muscle and the deep layer of the fascia. Within the middle third of the forehead, the deep layer of the galea was fused with the periosteum and firmly adhered. In the inferior caudal third of the forehead, the frontalis muscle was separated from the deep galeal aponeurosis and interdigitated with the orbicularis muscle. When the frontal muscle end was dissected free from the deep fascia by approximately 1 cm and pulled upward, no movement of the eyebrows was observed. Eyebrow elevation was only achieved by pulling on the inferior part of the muscle. CONCLUSIONS: Frontalis muscle movement occurs from the inferior caudal end towards the mid part of the muscle as it contracts centripetally on its superficial layer sliding over the deep part strongly attached to the deep fascia.

Sensory Evaluation of the Nipple-Areolar Complex Following Primary Breast Augmentation: A Comparison of Incision Approaches.

BACKGROUND: The central inframammary incisional approach for breast augmentation surgery disrupts the fifth anterior intercostal nerve-artery-vein-plexus. The authors hypothesized that preservation of the fifth anterior intercostal neurovascular pedicle might completely preserve nipple-areola complex (NAC) sensitivity after implant breast augmentation. OBJECTIVES: The aim of the study was to analyze if the use of a laterally displaced incision achieves better sensitivity results than the conventional median submammary incision in females who underwent primary breast augmentation surgery. METHODS: A group of 25 female patients (50 breasts) underwent a surgical protocol for primary prepectoral implant breast augmentation with a laterally displaced submammary incision. This group was compared to a similar group of 25 patients (50 breasts) who underwent breast augmentation through a conventional submammary central approach. Sensitivity testing with Semmes-Weinstein monofilaments was performed in both groups preoperatively and on postoperative days 2, 14, and 30, and after 6 months. RESULTS: Both groups were similar in age, BMI, comorbidities, and implant volumes. Preoperatively, all patients reported normal sensory function in both breasts. Postoperatively, in the laterally displaced incision group, sensory function remained normal in NAC areas, whereas in the conventional incision group, all cases presented the same degree of sensitivity diminution at Days 2, 14, and 30 (P = .000). At 6 months, all values were the same as at Day 30. CONCLUSIONS: Preservation of the fifth AIC pedicle resulted in complete preservation of preoperative NAC sensitivity. The laterally placed inframammary incision should be considered for patients undergoing primary prepectoral implant breast augmentation.

Fluorescence Imaging to Identify and Preserve Fifth Intercostal Sensory Nerves during Bilateral Nipple-sparing Mastectomies.

The use of nipple-sparing mastectomies has increased steadily over the past 10-15 years. However, one major source of patient dissatisfaction with both skin- and nipple-sparing mastectomies is lost skin and/or nipple sensation postoperatively due to intraoperative, iatrogenic sensory nerve injury. We summarize the case of a 41-year-old woman with BRCA(+) breast cancer who underwent bilateral, risk-reducing nipple-sparing mastectomies, immediately followed by bilateral, direct-to-implant breast reconstruction, in whom a prototype fluorescent imaging camera was used to facilitate sensory nerve identification and preservation. Preoperatively, tactile and thermal quantitative sensory testing were performed using a 30-gauge needle to determine baseline sensory function over both breasts. Then, nipple-sparing mastectomies and direct-to-implant reconstruction were performed. Using a laterally-displaced submammary approach, the anterior intercostal artery perforator neurovascular pedicle was preserved. Then a prototype camera, which emits near-ultraviolet light, was used to detect nerve autofluorescence. Intraoperatively under near-ultraviolet light, both the fifth intercostal nerve and its sensory branches auto-fluoresced clearly, so that surgery was completed without apparent injury to the fifth intercostal nerve or any of its branches. Postoperatively, the patient reported full sensory function throughout both breasts and both nipple-areolar complexes, which was confirmed on both tactile and thermal sensory testing at 3-month follow-up. The patient experienced no complications and rated her overall satisfaction with surgery on both breasts as 10 out of 10. To our knowledge, this is the first time sensory nerve auto-fluorescence has been reported to reduce the likelihood of intraoperative, iatrogenic nerve injury and preserve sensory function.

The deep inferior epigastric perforator flap: where we started and where we are now.

The deep inferior epigastric perforator (DIEP) flap has been performed since the early 1990s. This represented a significant advancement from the prior autologous options that required removal of all or a portion of various muscle groups. Over the years numerous advancements and modifications have been made to DIEP flap reconstruction that have further facilitated our ability to provide this option following mastectomy. Advancements with preoperative preparation, intraoperative techniques, and postoperative management have served to determine eligibility for DIEP flap reconstruction, improve surgical outcomes, reduce complications, reduce surgical operative time, and facilitate postoperative monitoring. Preoperative advancements have included vascular imaging to identify perforators. Intraoperative advancements have included using the internal mammary perforators as the optimal recipient vessels rather than the thoracodorsal, having a two-team approach with microsurgical reconstruction to reduce operative time and improve outcomes when compared to the single surgeon strategy, using a venous coupler rather than hand sewing the anastomosis, using tissue perfusion technology to determine the perfusion limits within the flap. Postoperative advancements include the use of technology to optimally monitor flaps as well as the use of using enhanced recovery after surgery pathways to improve the postoperative experience and promote early and safe discharge from the hospital. This manuscript will review the evolution of the DIEP flap as it relates to comparing our earlier techniques and strategies compared to our current techniques and strategies following mastectomy and breast reconstruction.

The reverse LICAP flap: A laterally based submammary perforator flap for breast reconstruction.

INTRODUCTION: The traditional donor sites for autologous breast reconstruction include the abdomen, thigh, buttock, and posterior thorax. Herein, we describe the use of the reverse lateral intercostal perforator (LICAP) flap originating from the submammary region as an option for breast reconstruction. METHODS: Fifteen patients (30 breasts) were included in this retrospective review. The procedure was performed for immediate reconstruction following a nipple sparing mastectomy utilizing an inframammary incision or an inverted T pattern with preservation of the fifth anterior intercostal perforator (n = 8), volume replacement after implant explantation (n = 5), and partial lower pole resurfacing with exteriorization of a portion of the LICAP skin paddle (n = 2). RESULTS: Flap survival was achieved in all patients. Three flaps (10%) had 1-2 cm of intraoperative distal tip ischemia, which was managed by excision prior to inset and closure. At the 12-month postoperative follow-up, stable results with good nipple position, breast shape, and projection were achieved in all patients. CONCLUSIONS: The reverse LICAP flap is a safe, effective, and reliable option for breast reconstruction following mastectomy.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design.

BACKGROUND: The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. METHODS: This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. RESULTS: Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. CONCLUSION: The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Betadine Soaking of Silicone Coupons Minimally Impacts Acellular Dermal Matrix Incorporation in a Preclinical Primate Model.

BACKGROUND: Microbial pathogens local to prosthetic breast devices may promote infection, inflammation, and capsular contracture. Although antimicrobial solutions have been used, their effects on human acellular dermal matrix (HADM) incorporation when used with prosthetic devices are unknown. The authors' objective was to histologically assess the effect of 10% povidone iodine (PI)-saturated tissue expander (TE) exposure on HADM biological response in a primate model. They hypothesized that PI exposure would not negatively affect the HADM biological response. METHODS: Samples (1.5 × 1.5 cm) from smooth silicone TEs were saturated in saline or PI for 2 minutes and sutured to HADM to create HADM/TE constructs. Primates implanted subcutaneously with saline ( n = 9) and PI-treated HADM/TE ( n = 9) construct pairs were evaluated histologically for biological response after 2 or 4 weeks by means of a host response scoring scale (1 to 9), including recellularization, neovascularization, and inflammation. Inflammatory cells (eosinophils, lymphocytes, neutrophils, histiocytes, foreign-body giant cells) and evidence of HADM remodeling (fibroblasts, vessels) were further evaluated by means of a cell-specific scoring scale (0 to 4) and corroborated by immunostaining (CD3, CD20, CD68, FSP-1, collagen type IV). RESULTS: Mean histology scores were similar between saline- and PI-exposed HADM at 2 weeks (5.3 ± 0.9 and 5.6 ± 0.5; P = 0.52) and 4 weeks (4.6 ± 1.0 and 4.2 ± 0.9; P = 0.44). There was no difference in inflammatory cell presence at 2 and 4 weeks between groups. Fibroblast infiltration differences were insignificant between groups but exhibited trends toward an increase between time points for saline (1.6 ± 0.7 to 1.8 ± 0.8) and PI (1.3 ± 0.8 to 1.8 ± 1.0) groups, suggesting HADM incorporation over time. CONCLUSION: Data suggest that HADM exposure to PI-treated TEs does not negatively affect inflammation, vascularization, recellularization, incorporation, or host response to HADM in this model. CLINICAL RELEVANCE STATEMENT: PI is a surgical pocket irrigant used to address bacterial colonization, but its impact on ADM incorporation is unknown. This study demonstrates similar biologic response to ADMs adjacent to PI- or saline-saturated TEs in a primate model.

Patient Satisfaction and Impact on Oral Health after Maxillary Rehabilitation Using a Personalized Additively Manufactured Subperiosteal Jaw Implant (AMSJI).

Subperiosteal implants (SIs) were first developed by Dahl in 1941 for oral rehabilitation in case of severe jaw atrophy. Over time, this technique was abandoned due to the high success rate of endosseous implants. The emergence of patient-specific implants and modern dentistry allowed a revisitation of this 80-year-old concept resulting in a novel "high-tech" SI implant. This study evaluates the clinical outcomes in forty patients after maxillary rehabilitation with an additively manufactured subperiosteal jaw implant (AMSJI®). The oral health impact profile-14 (OHIP-14) and numerical rating (NRS) scale were used to assess patient satisfaction and evaluate oral health. In total, fifteen men (mean age: 64.62 years, SD ± 6.75 years) and twenty-five women (mean age: 65.24 years, SD ± 6.77 years) were included, with a mean follow-up time of 917 days (SD ± 306.89 days) after AMSJI installation. Patients reported a mean OHIP-14 of 4.20 (SD ± 7.10) and a mean overall satisfaction based on the NRS of 52.25 (SD ± 4.00). Prosthetic rehabilitation was achieved in all patients. AMSJI is a valuable treatment option for patients with extreme jaw atrophy. Patients enjoy treatment benefits resulting in high patient satisfaction rates and impact on oral health.

Prevention and non-surgical treatment of soft tissue polly beak deformity after rhinoplasty: a scoping review.

The aim of this study is to map the available evidence of surgical preventive measures and postoperative methods for addressing supratip fibrosis (polly beak deformity) following rhinoplasty, to describe the postoperative results and to identify the most effective techniques. A scoping review was performed, selecting articles from the following medical electronic databases: PubMed, Cochrane Central, EMBASE, and Web of Science up to October 2022. The following keywords were used: supratip fullness, supratip deformity, polly beak deformity and supratip fibrosis. A total of 19 studies met the eligibility criteria. Of these 18 were included, and were divided into two categories: studies that solely used non-surgical management and studies that used operative techniques to prevent soft tissue polly beak deformity. Cartilaginous causes of polly beak deformity were excluded. Although a number of different methods are described in literature, the effectiveness and potential of each are still open to debate. Randomized controlled trials that use a standardized objective measurement method for soft tissue polly beak deformity are needed to objectively compare different methods.

Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy.

BACKGROUND: Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision. This study evaluated the benefit of preoperative vascular mapping using magnetic resonance imaging and Doppler ultrasonography to identify the different perforators to the breast and compared it to postoperative mapping. The authors' intent was to determine whether preoperative knowledge of the various vascular sources to the nipple-areola complex affected the outcome and vitality of the nipple-areola complex. METHODS: A prospective study was performed on 15 patients undergoing 25 nipple-sparing mastectomies for breast cancer or genetic predisposition. Ten patients underwent bilateral mastectomy, and five underwent unilateral mastectomy. Mean age was 52 years (range, 30 to 76 years). The mean patient body mass index was 22.4 kg/m2 (range, 20 to 35 kg/m2). Inclusion criteria consisted of breast cancer or genetic predisposition and grade 1 or 2 breast ptosis. Exclusion criteria included prior breast surgery, grade 3 ptosis, and gigantomastia. All patients underwent immediate direct-to-implant reconstruction. RESULTS: Preoperative vascular mapping by magnetic resonance imaging and external Doppler ultrasonography was performed in all 15 patients. In all 25 breasts, the fifth anterior intercostal artery perforator was identified preoperatively and preserved intraoperatively. Postoperative imaging demonstrated patency of the fifth anterior intercostal artery perforator vessels in all patients. Nipple-areola viability was demonstrated in all breasts. CONCLUSIONS: This study demonstrates that preoperative magnetic resonance imaging and Doppler ultrasonography for mapping breast perforator vessels is a useful strategy and should be considered for select patients undergoing nipple-sparing mastectomy. Identification of dominant perforators to the breast allowed mastectomy planning with preservation of the important perforator to the mastectomy skin flaps and nipple-areola complex. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.