Engineering Escherichia coli for efficient glutathione production.

Glutathione is a tripeptide of excellent value in the pharmaceutical, food, and cosmetic industries that is currently produced during yeast fermentation. In this case, glutathione accumulates intracellularly, which hinders high production. Here, we engineered Escherichia coli for the efficient production of glutathione. A total of 4.3 g/L glutathione was produced by overexpressing gshA and gshB, which encode cysteine glutamate ligase and glutathione synthetase, respectively, and most of the glutathione was excreted into the culture medium. Further improvements were achieved by inhibiting degradation (Δggt and ΔpepT); deleting gor (Δgor), which encodes glutathione oxide reductase; attenuating glutathione uptake (ΔyliABCD); and enhancing cysteine production (PompF-cysE). The engineered strain KG06 produced 19.6 g/L glutathione after 48 h of fed-batch fermentation with continuous addition of ammonium sulfate as the sulfur source. We also found that continuous feeding of glycine had a crucial role for effective glutathione production. The results of metabolic flux and metabolomic analyses suggested that the conversion of O-acetylserine to cysteine is the rate-limiting step in glutathione production by KG06. The use of sodium thiosulfate largely overcame this limitation, increasing the glutathione titer to 22.0 g/L, which is, to our knowledge, the highest titer reported to date in the literature. This study is the first report of glutathione fermentation without adding cysteine in E. coli. Our findings provide a great potential of E. coli fermentation process for the industrial production of glutathione.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging.

BACKGROUND: In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale. METHODS: We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured. RESULTS: In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs. CONCLUSION: The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Objective Assessment of the Repeated Botox Treatment to the Synkinesis of Facial Paralysis by the Integrated Electromyography.

BACKGROUND: The widely used botox type A (BTX-A) is effective against synkinesis in facial palsy sequelae. Repeated injections are necessary and permanent improvements have been reported. We objectively evaluated the changes in synkinesis at >6 months after BTX-A injection, including changes over time with the number of administrations. METHODS: In 48 patients who received multiple BTX-A injections, evaluation by the Sunnybrook Facial Grading System (FGS) and integrated electromyography (iEMG) was performed before treatment and at least 6 months after the first, second, and third BTX-A injection. The iEMG ratio on the affected and healthy sides was calculated for each mimetic muscle and mimic motion. RESULTS: There was no significant difference in the FGS synkinesis score before treatment and after the third injection, although an improvement was observed. The iEMG ratio was significantly improved in the orbicularis oculi with open-mouth smile and lip pucker after the third dose compared to before treatment. The orbicularis oris showed a significant improvement when the eyelids were closed, while the platysma showed a significant improvement when the eyelids were closed and when the lip was pursed. Multiple regression analysis revealed that the orbicularis oculi and platysma had a greater effect on the iEMG ratio for the number of treatments than other factors. CONCLUSIONS: Repeated BTX-A injections showed improvements in synkinesis for the orbicularis oculi, orbicularis oris, and platysma, even after >6 months, compared to before treatment.

[A framework for promoting and evaluating "Kayoi-no-ba" initiatives according to the Plan-Do-Check-Action cycle: The ACT-RECIPE framework].

Objective　In 2019, the Ministry of Health, Labour and Welfare emphasized the importance of promoting "Kayoi-no-ba" (or "places to go") initiatives according to the Plan-Do-Check-Action (PDCA) cycle. However, it proposed no specific promotion measures or standardized evaluation frameworks. This study is intended to propose a framework for local government officials to promote and evaluate "Kayoi-no-ba" initiatives according to the PDCA cycle.Methods　The working group (WG) conducted a narrative review of research and extracted evaluation models and indicators that could be used to create the framework. The co-researcher review committee discussed a draft framework prepared by the WG, and the WG revised it based on the discussion; this process was repeated four times. Using the completed framework, we calculated the score of the "Kayoi-no-ba" initiatives in 50 Tokyo municipalities and conducted regional correlation analyses on the relationship between the score of the "Kayoi-no-ba" initiatives in 50 Tokyo municipalities and the number of "Kayoi-no-ba" per 1,000 older persons.Results　The completed framework (named "ACT-RECIPE" by rearranging the underlined characters below) comprised the following six evaluation phases: (1) Comprehension: understanding the key lessons around disability and frailty prevention, and the necessity for "Kayoi-no-ba"; (2) Research and Planning: clarifying the current status of "Kayoi-no-ba," the strengths of the community, and the issues to be addressed through a community assessment, and developing a plan to resolve the issues; (3) Team Building and Collaboration: building a team by collaborating with organizations to solve problems; (4) Implementation: implementing the initiatives necessary to solve problems; (5) Evaluation: verifying changes in output and outcome indicators from the initiatives; and (6) Adjustment and Improvement: re-examining plans, teams, content, and goals based on the evaluation results. In these six phases, we designated 10 core items and accompanying subitems. The median score rate of the ACT-RECIPE framework in 50 municipalities was 75% for "Comprehension," 61% for "Research and Planning," 69% for "Team Building and Collaboration," 64% for "Implementation," 31% for "Evaluation," and 56% for "Adjustment and Improvement," and the mean ACT-RECIPE score rate was 57%. A significant positive correlation (rs=0.43, P=0.002) was observed between the ACT-RECIPE mean score rate and the number of "Kayoi-no-ba" per 1,000 older persons.Conclusion　We proposed the ACT-RECIPE as a framework for promoting and evaluating "Kayoi-no-ba" initiatives according to the PDCA cycle. We hope that this framework will lead to further progress in "Kayoi-no-ba" initiatives and facilitate evaluation of their effectiveness according to the PDCA cycle.

Long-Term Outcomes of Breast Cancer Patients with Local Recurrence After Mastectomy Undergoing Immediate Breast Reconstruction: A Retrospective Multi-institutional Study of 4153 Cases.

BACKGROUND: The number of breast cancer patients in Japan undergoing immediate breast reconstruction (IBR) has increased and the postoperative follow-up period has been extended. This study was conducted to clarify the clinical aspects of, and factors associated with, local recurrence (LR) after IBR. METHODS: This was a multicenter study which included 4153 early breast cancer patients who underwent IBR. Clinicopathological characteristics were examined and factors potentially contributing to LR were analyzed. Risk factors for LR were examined separately for non-invasive and invasive breast cancers. RESULTS: The median follow-up period was 75 months. The 7-year LR rates were 2.1% and 4.3% for non-invasive and invasive cancers, respectively (p < 0.001). The proportions of LR detected by palpation, subjective symptoms, and ultrasonography were 40.0%, 27.3%, and 25.9%, respectively. Overall, 75.7% of LR were solitary, and 92.7% of these cases had no further recurrences during the observational period. Multivariate analysis of LR for invasive cancer showed that skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM), the presence of lymphovascular invasion, cancer at the surgical margin, and not receiving radiation therapy were factors related to LR. The 7-year overall survival rates of the patients with LR and non-LR of invasive cancers were 92.5% and 97.3%, respectively, (p = 0.002). CONCLUSIONS: The rate of LR after IBR was acceptably low and IBR can thus be performed safely for early breast cancer patients. Invasive cancer, SSM/NSM, lymphovascular invasion, and/or cancer at the surgical margin should prompt awareness of the possibility of LR.

Plaque characterization of a saphenous vein graft by near-infrared spectroscopy and histopathology in a patient with a percutaneous coronary intervention.

Near-infrared spectroscopy (NIRS) is an intravascular imaging (IVUS) modality that detects lipid core plaques in the vessel wall, which are regarded as high-risk plaques for distal embolization in percutaneous coronary interventions (PCI). Saphenous vein graft (SVG) lesions have friable lipid-rich plaques and thrombus prone to distal embolization. The plaque characterization of SVG by NIRS was confirmed herein for the first time with histopathology before and after PCI. The present case was a man in his 60 s with a history of coronary artery bypass graft surgery. Coronary angiography revealed severe stenosis in multiple segments of the SVG to left circumflex artery (LCX). NIRS IVUS showed large amounts of lipidic materials at each segment before PCI. After balloon dilatation, NIRS IVUS revealed a marked reduction in yellow signals on chemography. A histopathological analysis of the captured specimen showed that it was mainly composed of fibrin and contained numerous histiocytes with foam cells, lymphocytes, and other cells, which was consistent with the histopathological findings of plaque rupture.

Carboazidation of Terminal Alkenes with Trimethylsilyl Azide and Cyclic Ethers Catalyzed by Copper Powder under Oxidative Conditions.

Copper-catalyzed carboazidation of alkenes with trimethylsilyl azide and cyclic ethers has been achieved. The employment of naturally abundant copper catalysts allowed cyclic ethers to be used as alkylating reagents under oxidative conditions. The use of styrene derivatives and 1,1-diaryl alkenes afforded carboazidation products. In addition, application of five- and six-membered cyclic ethers to the present reaction gave target organic molecules bearing azide and cyclic ether groups with perfect regioselectivity. Radical trapping and clock experiments revealed that the present reaction proceeded via the radical pathway. To further demonstrate the utility of this carboazidation reaction, transformations from the azide group to the related nitrogen-containing compounds were also performed.

Carcinogenic risk in the biliary epithelium of children with congenital biliary dilatation via the DNA damage repair pathway.

PURPOSES: Congenital biliary dilatation (CBD) is a high-risk factor for biliary tract cancer (BTC). We previously reported the potential for carcinogenesis in the biliary epithelium of patients with CBD. In this study, we investigated potential carcinogenetic pathways, focusing on the DNA damage repair response, in children with CBD and compared the findings with those in adults. METHODS: We enrolled 6 children with CBD and 10 adults with CBD without BTC who underwent extrahepatic bile duct resections, plus 4 control patients who underwent pancreaticoduodenectomy for non-biliary cancer. Levels of phosphorylated histone H2AX (γH2AX), MRE11, and Ku-70 in the biliary tract epithelium were evaluated by immunohistochemistry. RESULTS: The levels of γH2AX, MRE11, and Ku-70 were significantly higher in the gallbladder epithelium and bile duct epithelium of both children and adults than in controls. CONCLUSIONS: Children and adults with CBD might develop BTC via the DNA damage repair pathway, as evidenced by increased γH2AX, MRE11, and Ku-70 expression.

The triangular prism approximation method for volume estimation of deep inferior epigastric artery perforator flap in breast reconstruction.

BACKGROUND: Many methods to predict the amount of tissue needed for breast reconstruction have been reported, but some require complicated software and special systems. The purpose of this report was to present a simpler method for predicting the volume required for deep inferior epigastric artery perforator (DIEP) flaps. The accuracy of this method was evaluated based on both actual flap design and computed tomography. METHODS: The weight and horizontal (x cm) and vertical (y cm) lengths of the DIEP flap were recorded, and the maximum thickness of subcutaneous tissue (z cm) was measured from computed tomography in 36 cases of breast reconstruction using DIEP flap in our hospital performed between January 2019 and December 2020. Flap volume was calculated using three methods of approximation: triangular prisms using physical and CT measurements (1/2xyz cm3 ); quadrangular and triangular prisms using physical and CT measurements (3/4xyz cm3 ); and a previously reported method using measurements from CT angiography alone and calculation with a standard mathematical formula. These three groups were compared using Bland-Altman plots and intraclass correlation coefficients (ICCs) to assess consistency between predicted and measured values. RESULTS: On Bland-Altman plots, values were distributed almost randomly around the average value of the difference, and no proportional error was evident in the methods. The ICC between predicted and actual values of triangular prisms using physical and CT measurements was largest: ICC (1, 2) = 0.978 (0.825-0.981; 95% confidence interval for ICC). A sufficient flap volume was able to be transplanted in all cases. CONCLUSION: The methods presented appear useful to calculate flap volume closer to the measured value without complicated software systems. These results suggest that the method using two symmetric triangular prisms could predict volume more easily than previously reported methods and may facilitate good breast reconstruction.

Risk Factors for Postoperative Infection After Maxillary Reconstruction Using Skeletal Grafts.

Skeletal grafts are usually required to reconstruct defects after maxillectomy for acceptable aesthetic and functional results. Postoperative infection is a serious complication; however, few studies have evaluated the vulnerability to infection of various skeletal reconstructive materials used for maxillary reconstruction. A retrospective study was conducted on 53 cases in which maxillary skeletal reconstruction was performed between 2010 and 2021. The postoperative infection rate was compared between various skeletal reconstructive materials, including costal cartilage, scapula, fibula, ilium, cranium, and titanium mesh. In addition, the risk factors for postoperative infection were evaluated using 2-group comparison tests. Of 53 patients, 14 (25.4%) contracted an infection postoperatively. No significant differences were observed in the infection rates among the materials used for skeletal reconstruction. Cases undergoing secondary reconstruction tended to have a higher infection rate (34.4%) than primary reconstruction (14.3%). For nonvascularized skeletal grafts (41 cases), the concomitant use of soft-tissue flaps decreased the infection rate from 30.8% to 17.9%. Costal cartilage was the most frequently used material (31 cases), primarily for orbital floor reconstruction. Regarding the costal cartilage, nasal wall reconstruction had a higher infection rate (100%) than reconstruction of other parts of the maxilla (0.0%-17.9%). Nonvascularized skeletal grafts, mainly costal cartilage grafts, were safely used for maxillary reconstruction. However, caution should be exercised for postoperative infection in secondary cases and in cases where costal cartilage is used for nasal wall reconstruction. Covering nonvascularized skeletal grafts with soft-tissue flaps may be an effective countermeasure.

Outcomes of Restrictive Cardiomyopathy in Japanese Children　- A Retrospective Cohort Study.

BACKGROUND: There has been no nationwide survey on the prognosis of pediatric restrictive cardiomyopathy (RCM) in Japan; therefore, this retrospective multicentered study was designed to investigate the long-term survival rate of pediatric patients with RCM in Japan.Methods and Results: A multicentered, retrospective observational study was performed between 1990 and 2014 and included patients diagnosed with RCM who were aged <18 years from 18 Japanese institutions. A total of 54 patients were diagnosed with RCM. The median age at diagnosis was 4.4 years, and the median duration of observation was 2.2 years at the time of this study. Of these patients, 54% had symptoms, including heart failure. Twelve patients died without heart transplantation, mostly due to heart failure. The median time to death from diagnosis was 2.5 years. Freedom from death at 1, 5, and 10 years was 91%, 68%, and 62%, respectively. Death occurred within 5 years of diagnosis in most patients. Twenty-two patients underwent heart transplantation. Freedom from heart transplantation at 1, 5, and 10 years was 77%, 58%, and 53%, respectively. Freedom from death or heart transplantation at 1, 5, and 10 years was 72%, 40%, and 34%, respectively. The presence of symptoms was a risk factor for death or transplantation. CONCLUSIONS: The prognosis of pediatric RCM is poor, and the heart transplantation rate is low in Japan.

Outcomes of hypertrophic cardiomyopathy in Japanese children: a retrospective cohort study.

There has been no multicenter study on the prognosis of pediatric hypertrophic cardiomyopathy (HCM) in Japan. Therefore, we conducted a retrospective multicenter observational study on the long-term survival rate in patients diagnosed with HCM under the age of 18 between 1990 and 2014. Twenty institutions participated. A total of 180 patients were identified. The median age at diagnosis was 5.8 years old and median duration of observation was 8.3 years. Although six patients (3%) deteriorated into the dilated phase of HCM, no patient received heart transplantation. Freedom from death at 1, 5, 10, and 20 years were 97%, 92%, 84%, and 80%, respectively. There were 26 deaths. Among them, 11 patients died suddenly, presumably due to arrhythmia, and 15 patients died of heart failure. The presence of heart failure symptoms and a greater cardiothoracic ratio were significant risk factors for heart failure-related death. There were no significant risk factors identified for arrhythmia-related death. In conclusion, the prognosis of pediatric HCM in Japan is good and similar to those reported in population-based studies in the United States and Australia. Significant risk factors for heart failure-related death were identified in pediatric patients with HCM in Japan.

Risk factors for metachronous contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for unilateral inguinal hernia in children.

PURPOSES: We use the laparoscopic percutaneous extraperitoneal closure (LPEC) method as the standard procedure for pediatric inguinal hernia. Despite judging there to be no contralateral patent processus vaginalis (PPV) at the time of the first LPEC, we experienced five cases in which metachronous contralateral inguinal hernia (MCH) developed, so we report the characteristics, including the predictors. METHODS: For pediatric inguinal hernia, the LPEC method was used in 1277 cases from 2005 to 2019 in our department. Of these, 374 patients underwent unilateral LPEC, and we compared the 5 patients with MCH onset and the 369 without MCH onset. The items to be examined were the gender, age, presence of a low birth weight, initial-onset side, and contralateral internal inguinal ring classification. RESULTS: There was no significant difference in the gender, age, initial-onset side, or contralateral internal inguinal ring classification between the two groups. Low-birth-weight infants were significantly more common among those with MCH than among those without MCH. CONCLUSIONS: The only predictor of a contralateral onset after LPEC for pediatric inguinal hernia was a low birth weight. Therefore, for the above-mentioned unilateral LPEC cases, the possibility of a contralateral onset after LPEC due to acquired factors rather than congenital factors should be considered.

Risk of carcinogenesis in the biliary epithelium of children with congenital biliary dilatation through epigenetic and genetic regulation.

PURPOSES: Congenital biliary dilatation (CBD), defined as pancreaticobiliary maljunction (PBM) with biliary dilatation, is a high risk factor for biliary tract cancer (BTC). KRAS and p53 mutations reportedly affect this process, but the mechanisms are unclear, as is the likelihood of BTC later in life in children with CBD. We investigated potential carcinogenetic pathways in children with CBD compared with adults. METHODS: The subjects of this study were nine children with CBD and 13 adults with PBM (10 dilated, 3 non-dilated) without BTC who underwent extrahepatic bile duct resections, as well as four control patients who underwent pancreaticoduodenectomy for non-biliary cancer. We evaluated expressions of Ki-67, KRAS, p53, histone deacetylase (HDAC) and activation-induced cytidine deaminase (AID) in the biliary tract epithelium immunohistochemically. RESULTS: The Ki-67 labeling index (LI) and expressions of KRAS, p53, HDAC, and AID in the gallbladder epithelium were significantly higher or tended to be higher in both the children with CBD and the adults with PBM than in the controls. CONCLUSIONS: BTC may develop later in children with CBD and in adults with PBM, via HDAC and AID expression and through epigenetic and genetic regulation.

Comparison of Lumbar Artery and Superior Gluteal Artery Perforator Flaps for Breast Reconstruction: Multislice CT-Based Anatomical Study.

BACKGROUND: Although the deep inferior epigastric artery perforator flap is the criterion standard for autologous breast reconstruction, lumbar artery perforator (LAP) and superior gluteal artery perforator (SGAP) flaps are recent trends as alternatives. The purpose of our study was to clarify differences of these flaps based on multislice CT findings of the same patient. METHODS: Retrospective study was conducted on 58 patients who underwent preoperative contrast-enhanced multislice CT for breast reconstruction using deep inferior epigastric artery perforator. Of these, 32 patients' data were evaluated excluding 26 patients' data either for the lumbar or gluteal fat being outside the imaging range or for nondepiction of the vascular pedicle origin of LAP or SGAP flap. Vascular pedicle diameter, pedicle length, and subcutaneous fat thickness were measured for LAP and SGAP flaps. RESULTS: The vascular pedicle diameter, pedicle length, and fat thickness were 2.1 (SD, 0.3) mm, 3.4 (SD, 0.4) cm, and 4.9 (SD, 1.0) cm, respectively, for LAP flaps; and 1.7 (SD, 0.2) mm, 5.6 (SD, 1.1) cm, and 2.7 (SD, 0.7) cm, respectively, for SGAP flaps. CONCLUSIONS: The LAP flaps had thicker subcutaneous fat and a larger vascular pedicle diameter, whereas the SGAP flaps had a longer vascular pedicle. As donor material for breast reconstruction, the LAP flap is indicated for cases where absolute volume is needed; otherwise, the SGAP flap is more advantageous as it facilitates vascular anastomosis with its longer vascular pedicle.

Identifying Predictors of Radiographic Distal Phalangeal Nonunion After Fingertip Replantation.

PURPOSE: This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation. METHODS: This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation. RESULTS: At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68). CONCLUSIONS: The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparative Blink Analysis in Patients With Established Facial Paralysis Using High-Speed Video Analysis.

ABSTRACT: This study analyzed the blink characteristics of patients with incomplete and complete facial paralysis. The authors measured and compared the palpebral distance, eyelid movement distance, and the eye-closing ratio of blinks in 55 patients with Bell's palsy or Ramsay Hunt syndrome (Bell & Hunt group) and 14 with complete paralysis (Complete Paralysis group). in the Bell & Hunt group, the palpebral distance (7.94 mm) was smaller on the paralyzed side than on the non-paralyzed side (9.61 mm). The eyeclosing ratio and the upper eyelid movement were reduced on the paralyzed side (65.3% versus 93.7%, 4.61 versus 7.97 mm) and in the Complete Paralysis group (25.3% versus 94.7%, 2.10 versus 8.49 mm). In the Bell & Hunt group, movement of the upper eyelid on the paralyzed side was weakened despite palpebral contracture. The Complete Paralysis group exhibited highly reduced movement in both the upper and lower eyelids.

Influence of Marker Number and Position on Accuracy of Breast Measurement With Three-Dimensional Camera.

BACKGROUND: The VECTRA H1 three-dimensional (3D) imaging system (Canfield Scientific, Parsippany, NJ) enables easy 3D image construction and measurement. Although the number and positions of markers on the skin for image synthesis might affect accuracy of measurements, few studies have mentioned the possibility. This study investigated the accuracy and reproducibility of distance measurements using VECTRA H1, focusing on the number and positions of markers. METHODS: A total of 3, 5, or 7 markers were attached to a female breast model including lateral markers 6 cm from the midline and photographed with VECTRA. Five markers were configured in more two ways, with the lateral markers either positioned 3 cm outside the midline (narrow interval) or 9 cm outside the midline (wide interval). 3D models were created three times under each condition, for a total of 15 models. Differences (measurement error) between measured values on 3D models and actual measured values were verified for six distances, such as distance between the nipples. RESULTS: The average difference was 11.1 mm with 3 markers (95% confidence interval (CI), 4.38-17.7 mm, p = 0.0028). In comparison, average difference was -0.395 mm (-0.866 to 0.0763 mm, p = 0.095) with 5 markers, and 0.139 mm (-0186 to 0.465 mm, p = 0.379) with 7 markers, all less than 1 mm. Average difference with narrow interval 5 markers was larger than one with wide interval. CONCLUSIONS: In 3D imaging of the breast using VECTRA H1, distance measurements offering clinically satisfactory accuracy can be made by setting appropriate marker conditions. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reliability of Temporal Vascular Anastomosis and Techniques for Better Outcomes.

BACKGROUND: Although there are several potential recipient vessels in the neck, those in the temporal region are limited. In skull base reconstruction, there are difficulties associated with the anastomosing recipient vessels in the neck region since long nutrient vessels are needed in the flap. We evaluated the reliability of temporal vascular anastomosis by comparing surgical outcomes between reconstructive methods and examined which surgical procedures may achieve better results. METHODS: We examined the medical records of free tissue transfer cases between April 2007 and March 2018. Seventy-three surgeries were performed in the temporal region, including skull base reconstruction in 48, head and neck reconstruction (without skull base) in 16, and secondary surgery for head deformities in nine cases. In total, 445 neck surgeries were performed. Postoperative complications were retrospectively analyzed. RESULTS: The postoperative complication rates were 8.2 and 2.7% for all temporal and neck surgeries, respectively. There were no arterial complications in the temporal region and all of the six postoperative anastomotic complications were due to venous thrombosis. In contrast, there were 12 cases of vascular anastomotic complications, with six cases each of arterial and venous thrombosis in the neck. In the temporal region, the complication rate was 2.1% for skull base reconstruction, 11% for secondary revision, and 25% in head and neck reconstruction. The corresponding values for middle temporal vein (MTV) usage rates were 54, 22, and 25%. In skull base reconstruction, a coronal incision was made in all cases. A more frequent use of the MTV was associated with a reduced complication rate. CONCLUSION: The low complication rate in the temporal region was attributed to the wide surgical field and low tension of anastomotic vessels. Multiple venous anastomoses, including those of the MTV, are recommended to prevent complications.

Prognosis of Subcutaneous Mastectomy for Special Types of Breast Cancer.

Background and objectives: In the treatment of the special type of breast cancer (STBC), the choice of chemotherapeutic agents is often based on the characteristic features of the histological type. On the other hand, the surgical strategy is usually determined by the tumor size and presence of lymph node metastasis, and the indication for immediate reconstruction is rarely discussed based on the histological type. The prognoses of STBC and invasive ductal carcinoma of the breast (IDC) patients who underwent subcutaneous mastectomy (SCM) with immediate reconstruction at our institution were compared. Materials and Methods: A total of 254 patients with SCM with immediate reconstruction from 1998 to 2018 were included; their tumor diameter or induration was less than 25 mm, and it was not in close proximity to the skin. Preoperative chemotherapy and non-invasive cancer cases were excluded. Results: The number of patients was 166 for skin-sparing mastectomy (SSM) and 88 for nipple-sparing mastectomy (NSM). The reconstructive techniques were deep inferior epigastric artery perforator flap (DIEP) reconstruction in 43 cases, latissimus dorsi flap reconstruction (LDflap) in 63 cases, tissue expander (TE) in 117 cases, and transverse rectus abdominis myocutaneous flap/vertical rectus abdominis myocutaneous flap (TRAM/VRAM) reconstruction in 31 cases. The histological types of breast cancer were 211 IDC and 43 STBC; 17 were mucinous carcinoma (MUC), 17 were invasive lobular carcinoma (ILC), 6 were apocrine carcinoma, 1 was tubular carcinoma, and 2 were invasive micropapillary carcinoma. There was no difference in local recurrence or disease-free survival (LRFS, DFS) between IDC and STBC, and overall survival (OS) was significantly longer in STBC. OS was better in the STBC group because SCM with immediate reconstruction was performed for STBC, which is a histological type with a relatively good prognosis. Highly malignant histological types, such as squamous cell carcinoma or metaplastic carcinoma, were totally absent in this study. Conclusions: The indications for SCM with immediate reconstruction for relatively common STBCs such as MUC and ILC can be the same as for IDC.