Enlarged postauricular nodules in a young South Asian man.

We report a 19-year-old South Asian man with progressively enlarging postauricular nodules over a 5-year period, which were eventually treated by surgical resection.

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes.

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Trachea Reconstruction with Single-Stage Composite Flaps in a Rabbit Model.

BACKGROUND: Trachea reconstruction requires creation of a functional lining, semirigid support, and vascularity. We aimed to design composite flaps with these three components in a rabbit model. METHODS: Circumferential (n = 9) and partial anterior (n = 8) tracheal defects were created in rabbits. A circumferential defect was reconstructed with a tubed ear flap incorporating cartilage for support and skin for lining. This was pedicled on the posterior auricular vessels and tunneled into the neck to bridge the defect. In the second experiment, a longitudinal anterior trachea defect was patched with a pedicled rib cartilage and intercostal muscle flap based on the internal mammary vessels. The vascularized fascia over the intercostal muscles replaced the lining while the cartilage provided support. Postoperatively, the rabbits were monitored clinically and endoscopically. The tracheal constructs were examined histologically after the animals were sacrificed. RESULTS: Rabbits with circumferential defects reconstructed with the ear flap survived up to 6 months. Histology demonstrated vascularized cartilage with good integration of the flap with native trachea. However, hair growth and skin desquamation resulted in airway obstruction in the long term. In the second experiment, all the rabbits survived without respiratory distress, and the intercostal muscle fascia was completely covered by native respiratory epithelium. CONCLUSION: We described two experimental techniques using autologous composite flaps for single-stage trachea reconstruction in a rabbit model. Skin was a poor lining replacement, whereas vascularized muscle fascia became covered with respiratory epithelium. A rib cartilage and muscle flap could potentially be used for reconstruction of partial defects in humans.

Soft Tissue Reconstruction and Facial Reanimation With Bilateral Latissimus Dorsi Flaps After Extensive Resection of Head and Neck Arteriovenous Malformation: A Case Report.

We report a rare case of a 37-year-old man who presented with a huge arteriovenous malformation in the head and neck region. After resection, the 30 × 25 cm defect was reconstructed with a preexpanded musculocutaneous latissimus dorsi flap. The facial nerve had to be sacrificed during the resection, and smile reanimation was restored in a second operation with the contralateral latissimus muscle flap. A 15-cm length of thoracodorsal nerve was dissected and was anastomosed to the contralateral zygomatic branch in a single stage. He recovered well without any significant complications. At 6 years follow-up, there was no further growth of the arteriovenous malformation, and he had a spontaneous smile.

Large animal models for long-segment tracheal reconstruction: a systematic review.

BACKGROUND: The reconstruction of extensive tracheal defects is an unresolved problem. Despite decades of research, a reliable and practical substitute remains to be found. While there have been clinical reports of successful long-segment tracheal reconstruction, reproducibility and widespread applicability of these techniques have yet to be achieved. Large animals such as the dog, pig, sheep, and goat have comparable tracheal morphology and physiology to humans making them useful preclinical models to screen potential therapeutic strategies. MATERIALS AND METHODS: The literature was reviewed to identify large animal models commonly used for tracheal reconstruction. A systematic search of PubMed and EMBASE was performed for large animal studies reporting on the reconstruction of long-segment tracheal and carinal defects. Fifty-seven studies were identified for analysis. RESULTS: There is no standard large animal model available for tracheal research. In recent years, livestock species have gained favor over dogs as animal models in this field. The minimum requirements for successful tracheal replacement are rigidity, vascularity, and epithelial lining. Early attempts with synthetic prostheses were met with disappointing results. An autologous tracheal substitute is ideal but hindered by limited donor site availability and the lack of a dominant vascular pedicle for microsurgical reconstruction. Although tracheal allotransplantation enables like-for-like replacement, there are unresolved issues relating to graft vascularity, immunosuppression, and graft preservation. Tissue engineering holds great promise; however, the optimal combination of scaffold, cells, and culture conditions is still indeterminate. CONCLUSIONS: Despite impressive advances in tracheal reconstruction, a durable substitute for extended tracheal defects continues to be elusive.

Association of reactive oxygen species levels and radioresistance in cancer stem cells.

The metabolism of oxygen, although central to life, produces reactive oxygen species (ROS) that have been implicated in processes as diverse as cancer, cardiovascular disease and ageing. It has recently been shown that central nervous system stem cells and haematopoietic stem cells and early progenitors contain lower levels of ROS than their more mature progeny, and that these differences are critical for maintaining stem cell function. We proposed that epithelial tissue stem cells and their cancer stem cell (CSC) counterparts may also share this property. Here we show that normal mammary epithelial stem cells contain lower concentrations of ROS than their more mature progeny cells. Notably, subsets of CSCs in some human and murine breast tumours contain lower ROS levels than corresponding non-tumorigenic cells (NTCs). Consistent with ROS being critical mediators of ionizing-radiation-induced cell killing, CSCs in these tumours develop less DNA damage and are preferentially spared after irradiation compared to NTCs. Lower ROS levels in CSCs are associated with increased expression of free radical scavenging systems. Pharmacological depletion of ROS scavengers in CSCs markedly decreases their clonogenicity and results in radiosensitization. These results indicate that, similar to normal tissue stem cells, subsets of CSCs in some tumours contain lower ROS levels and enhanced ROS defences compared to their non-tumorigenic progeny, which may contribute to tumour radioresistance.

Long-term results using a treatment algorithm for chronic sesamoiditis of the thumb metacarpophalangeal joint.

PURPOSE: We report a series of 18 patients with chronic sesamoiditis of the metacarpophalangeal joint of the thumb treated in the period from 1997 to 2002. We describe a diagnostic clinical test (sesamoid provocation test [SPT]) and present the long-term results of the senior author's treatment algorithm. METHODS: The study included 20 thumbs in 18 patients (8 men and 10 women) with an average age of 36 years. The mean duration of symptoms at initial presentation was 6 months. The dominant thumb was symptomatic in 80% of patients, and 30% of patients gave history of prior trauma. The diagnosis was made clinically and aided by the SPT. Radiographs were normal in 65% of thumbs. The treatment algorithm consisted of steroid injection(s) into the subsesamoid joint. Sesamoidectomy was reserved for patients who were symptomatic (visual analog pain score ≥ 3) after 2 steroid injections. The patients were contacted by telephone in 2010 for an assessment of long-term results. RESULTS: Eight thumbs improved with a single steroid injection whereas 5 thumbs required a second steroid injection. Of the 6 thumbs that underwent sesamoidectomy, 1 required secondary surgery for recurrent symptoms. At long-term follow-up (average, 9 y), 1 patient, who had declined sesamoidectomy, continued to have persistent pain affecting thumb function. CONCLUSIONS: Previous reports have suggested that nonoperative treatment is not effective in the management of chronic sesamoiditis. We found that steroid injections were an acceptable treatment modality with long-lasting results. Failures can be successfully treated with sesamoidectomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Versatility of the turn-around technique of the lateral arm flap for hand reconstruction.

The lateral arm flap is a popular flap for hand resurfacing. Despite its many advantages, its use is restricted by the available width of the flap. We describe the application of this long and narrow flap in a turn-around manner, greatly increasing its versatility while achieving primary closure of the donor site. The lateral arm flap was designed with extension onto the forearm (extended lateral arm flap) and harvested in the usual manner. During inset, the distal segment of the flap is brought through a 180 degree "U-turn" to lie adjacent to the proximal segment. We analyzed the outcomes of 31 turn-around lateral arm flaps performed between 1988 and 2008. All flaps healed well without any vascular compromise. Reconstruction of defects with a variety of configurations was performed with a maximum flap size of 144 cm. Four patients required split skin grafting to the forearm. Primary closure of the lateral arm donor site was achieved in all patients. In this article, we demonstrate the ease, reliability, and versatility of this simple modification in extending the usefulness of the lateral arm flap in hand reconstruction.

Surgical anatomy of the medial sural artery perforator flap.

BACKGROUND: The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap. METHODS: Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks. RESULTS: The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases. CONCLUSION: Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications. CLINICAL QUESTION: TherapeuticLevel of Evidence: IV.

Modifications of the radial forearm flap phalloplasty for female-to-male gender reassignment.

The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.

Variability in the development of synkinesis in a rabbit facial nerve axotomy model.

OBJECTIVE: Weakness and synkinesis (involuntary cocontraction of different muscle groups) are common sequelae after facial nerve injury. We describe a rabbit model of facial nerve axotomy and repair, which can be used to study such sequelae and propose a grading tool to assess the facial movement outcomes. Using this rabbit model, we assess the effect of delaying facial nerve repair on the quality of the clinical result. METHODS: A total of 15 rabbits (30 facial halves) were divided into 4 groups: control, facial nerve main trunk axotomy and immediate repair, axotomy and repair at 2.5 weeks as well as axotomy, and repair at 2 months. Functional recovery was graded according to the observable criteria. We performed retrograde fluorescence labelling of the distal facial nerve branches and assessed the distribution of tracers in the facial nucleus. RESULTS: A consistent model of weakness and synkinesis was produced in all rabbits after immediate axotomy and repair. A grading tool was used to clinically grade the quality of the recovery. The somatotopy of the facial nucleus was disrupted, with axons projecting from the facial nucleus to incorrect facial muscle groups. Varying the denervation time before repair affected the quality of the recovery. The worst result was noted when repair was delayed for 2 months. Subtle changes in the pattern and severity of synkinesis was noted among the different treatment groups. CONCLUSION: A slight delay in nerve repair by 2.5 weeks as well as contralateral facial paralysis (analogous to botulinum toxin (BTX) injection) appear to improve eye recovery and reduce synkinesis. Because of the large size of the rabbit, such variability in synkinesis severity can be graded.

Heterodigital vascular island flap for simultaneous resurfacing and revascularization of digits.

Devascularized digits with segmental skin and vessel loss require revascularization and resurfacing. This can be addressed by using a heterodigital vascular island flap. This flap brings with it an appropriately sized pristine artery of optimal length for revascularization and provides simultaneous skin cover. We describe 3 cases. Primary wound healing was achieved in all patients with good functional recovery and acceptable donor site morbidity. We compare the options available for reconstructing such defects and discuss other possible surgical indications for this flap.

Partial ulnar nerve transfer to the nerve to the biceps for the treatment of brachial plexopathy in metastatic breast carcinoma: case report.

Brachial plexus neuropathy can cause progressive pain and disability in patients with breast cancer. Metastatic spread and radiation injury are the most common causes in these patients. We report a case of partial ulnar nerve transfer to the nerve to the biceps muscle to restore elbow flexion in a patient with combined radiation-induced and metastatic brachial plexopathy.

Splenic infarction. A rare presentation of anaplastic pancreatic carcinoma and a review of the literature.

CONTEXT: Anaplastic carcinoma of the pancreas is a rare variant of ductal adenocarcinoma. The histogenesis and biologic behavior of these tumors are still controversial. They occur in elderly men and are associated with a very poor prognosis. CASE REPORT: We report a case of advanced anaplastic carcinoma in a 41-year-old man who presented with splenic infarction. He had a prolonged survival of 16 months from diagnosis. CONCLUSION: Splenic infarction is a most unusual acute presentation of pancreatic carcinoma, which may require emergency tumor resection and splenectomy.

Delayed bipedicled nasolabial flap in facial reconstruction.

BACKGROUND: The nasolabial flap is ideal for reconstruction of the nasal alar subunit due to its proximity, color and contour match, and well-placed donor scar. When raised as a random-pattern flap, there is a risk of vascular compromise to the tip with increased flap length and aggressive flap thinning. Surgical delay can greatly improve the chances of tip survival, allowing the harvest of longer flaps with greater reach. METHODS: We describe our technique of lengthening the nasolabial flap through multiple delay procedures. A bipedicled flap was first raised and then transferred as a unipedicled flap with a 6:1 length-to-width ratio. During the delay process, the flap tip was thinned to the subdermal layer. RESULTS: In our case series of seven patients, defects as far as the medial canthal area and contralateral ala were reconstructed successfully with no incidence of tip necrosis or flap loss. The resultant flaps were thin enough to be folded over for the reconstruction of alar rim defects. CONCLUSIONS: We highlight the success of our surgical technique in creating thin and robust nasolabial flaps for the reconstruction of full-thickness defects around the nose.

Use of complementary and alternative medicine in paediatric oncology patients in Singapore.

INTRODUCTION: Complementary and alternative medicine (CAM) is garnering increasing interest and acceptance among the general population. Although usage is thought to be widespread among paediatric cancer patients, local studies have not been done. We aimed to investigate the prevalence and predictors of CAM usage in paediatric cancer patients in a single institution. MATERIALS AND METHODS: Parents of 73 paediatric cancer patients treated at KK Women's & Children's Hospital completed an interviewer-administered questionnaire. Data about the types of CAM therapies used, motivations for use, adverse effects, costs and discussion of usage with the patient's physician were obtained. General perceptions towards CAM and conventional medicine were explored. A subsequent telephone survey enquired about spirituality, benefits of CAM use and overall satisfaction with the therapies. RESULTS: Two-thirds of patients used at least 1 CAM treatment, mainly as supportive adjuncts to conventional cancer treatment. Dietary changes, health supplements, herbal tea and bird's nest were the most common therapies used. Few patients (8.1%) consulted a CAM practitioner. Positive predictors of CAM usage included being of Chinese race, the practice of Buddhism or Taoism, the use of CAM prior to diagnosis, perception of CAM effectiveness and dissatisfaction with conventional treatment. Significantly, 55.1% of the parents had not discussed their CAM usage with their child's physician. CONCLUSIONS: A substantial proportion of paediatric cancer patients utilises CAM therapies, often without their physician's knowledge. Healthcare providers need to remain cognisant of the potential implications of CAM usage in order to proactively counsel patients. This would ensure that conventional therapy remains uncompromised.

Nipple reconstruction with rolled dermal graft support.

BACKGROUND: Loss of nipple projection is a common problem following nipple reconstruction. The aim of this study was to demonstrate that the use of a tightly rolled dermal graft is effective in the long-term maintenance of nipple projection. METHODS: Nipple reconstruction was performed using the C-V flap technique. A dermal graft was harvested from the dog-ear portion of previous scars. The graft was rolled tightly into a compact cylinder and used to augment the nipple reconstruction. Postoperatively, stacked Allevyn dressing was used for protecting the nipple from compression for a minimum of two months. Nipple projection was measured at the time of surgery and at 12 months postoperatively. RESULTS: Forty nipple reconstructions were performed using this technique. There were 19 transverse rectus abdominis musculocutaneous (TRAM) flaps, 10 latissimus dorsi (LD) flaps, and 11 tissue-expanded breast mounds. At one year, the mean projection was 0.80 cm (range, 0.62-1.22 cm). The twelve-month average maintenance of nipple projection was 70.2% for the TRAM flap group, 76.3% for the LD flap group, and 61.8% for the tissue-expanded group. In two patients with previous irradiation of the reconstructed breasts, relatively poor maintenance of nipple projection was noted (45.7%). No complications were noted, and all of the donor sites healed well primarily. CONCLUSIONS: Our results demonstrated that the use of a C-V flap with a tightly rolled dermal graft for nipple reconstruction improves the long-term maintenance of nipple projection. Its advantages include reproducibility, technical simplicity, cost-effectiveness, and minimal donor site morbidity.

Vallecular varix causing diagnostic confusion in hematemesis.

BACKGROUND: Hematemesis is a common and dramatic presentation of upper gastrointestinal bleeding and is a source of significant morbidity and mortality. Common causes include peptic ulcer disease and varices. However, endoscopists need to be aware of other rare causes to avoid a delay in diagnosis, which may be potentially fatal. METHODS AND RESULTS: We present a case of vallecular varix causing recurrent hematemesis and successfully treated with sclerosant injection. We also review the literature regarding its pathogenesis and treatment. CONCLUSIONS: Vallecular varicosities are a rare cause of life-threatening bleeding from the aerodigestive tract. The area should be targeted early for evaluation especially in cases of bleeding of unknown origin.