Implant-Based Gluteal Augmentation: Comparing Complications Between Single- and Double-Incision Techniques.

BACKGROUND: Gluteal implants are gaining popularity as an alternative to fat grafting for gluteal augmentation. This study aims to compare complication rates between single- and double-incision techniques for implant placement in gluteal augmentation from a single surgeon's experience. METHODS: Retrospective analysis of a single surgeon's implant-based gluteal augmentations was conducted between October 2018 and August 2022. Consecutive patient cases were reviewed at the beginning and end of the designated period to compare both incision techniques after switching from the single- to double-incision technique in September 2020. Demographics and postoperative complications were compared. Statistical comparisons were made using the independent sample t-test for quantitative variables and the Fisher's exact test for categorical variables. RESULTS: The study included 134 single-incision patients (247 implants) and 47 double-incision patients (91 implants). Baseline demographic and clinical characteristics between the two groups were similar. Overall complication rate per implant was higher in the single-incision group (16.6% vs. 6.6%, p = 0.02). The most common complication per implant was delayed wound healing (single incision: 9.7%, double incision: 5.5%). The odds ratio of developing at least one complication in the double compared to the single-incision group was 0.44 (95% CI: 0.19, 0.92). CONCLUSIONS: The double incision technique demonstrates a lower complication rate than the single-incision technique for implant-based gluteal augmentation. The most common complication in both groups was delayed wound healing which responded in most patients to conservative wound care. These results support using the double-incision technique for implant-based gluteal augmentation. LEVEL OF EVIDENCE III: 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 .

Surgical outcomes and revision rates for velopharyngeal insufficiency (VPI) in syndromic and non-syndromic children: A systematic review and meta-analysis.

PURPOSE: To evaluate pre- and post-operative resonance, surgical technique, revision rate, and revision indication among syndromic and non-syndromic children with velopharyngeal insufficiency (VPI). MATERIALS AND METHODS: A systematic review was conducted through July 2022. Children surgically treated for VPI were included. A meta-analysis of single means, proportions, comparison of proportions, and mean differences with 95 % confidence interval [CI] was conducted. RESULTS: Twenty-three articles (n = 1437) were included in the analysis. The most common surgery was Sphincter Pharyngoplasty (SP), 62.6 % [31.3-88.9] for syndromic and 76.3 % [37.5-98.9] for non-syndromic children. Among all surgical techniques, for syndromic and non-syndromic children, 54.8 % [30.9-77.5] and 73.9 % [61.3-84.6] obtained normal resonance post-operatively, respectively. Syndromic patients obtained normal resonance post-operatively in 83.3 % [57.7-96.6] of Combined Furlow Palatoplasty and Sphincter Pharyngoplasty (CPSP), 72.6 % [54.5-87.5] of Pharyngeal Flap (PF), and 45.1 % [13.2-79.8] of Sphincter Pharyngoplasty (SP) surgeries. Non-syndromic patients obtained normal resonance post-operatively in 79.2 % [66.4-88.8] of PF and 75.2 % [61.8-86.5] of SP surgeries. The revision rate for syndromic and non-syndromic patients was 19.9 % [15.0-25.6] and 11.3 % [5.8-18.3], respectively. The difference was statistically significant, 8.6 % [2.9-15.0, p = 0.003]. Syndromic patients who underwent PF were least likely to undergo revision surgery as compared to SP and CPSP, 7.7 % [2.3-17.9] vs. 23.7 % [15.5-33.1] and 15.3 % [2.8-40.7], respectively. CONCLUSIONS: Syndromic children had higher revision rates and were significantly less likely to obtain normal resonance following primary surgery than non-syndromic patients. Among syndromic children, PF and CPSP have been shown to improve resonance and reduce revision rates more so than SP alone.

Structural Support for Large to Total Nasal Reconstruction.

When large defects of the nose are present, it is imperative to address all 3 layers: the external skin envelope, the osteocartilaginous support, and the inner mucosal lining. The middle structural framework is the primary factor in determining the overall shape of the nose, in addition to facilitating a functional and patent airway. As such, its reconstruction must be robust enough to provide lasting osteocartilaginous support while minimizing disfiguring bulk. The goal is replacement of missing tissue with grafts of similar strength, size, and shape. This article will review approaches to the reconstruction of structural support in large nasal defects.

Androgen receptor splice variants drive castration-resistant prostate cancer metastasis by activating distinct transcriptional programs.

One critical mechanism through which prostate cancer (PCa) adapts to treatments targeting androgen receptor (AR) signaling is the emergence of ligand-binding domain-truncated and constitutively active AR splice variants, particularly AR-V7. While AR-V7 has been intensively studied, its ability to activate distinct biological functions compared with the full-length AR (AR-FL), and its role in regulating the metastatic progression of castration-resistant PCa (CRPC), remain unclear. Our study found that, under castrated conditions, AR-V7 strongly induced osteoblastic bone lesions, a response not observed with AR-FL overexpression. Through combined ChIP-seq, ATAC-seq, and RNA-seq analyses, we demonstrated that AR-V7 uniquely accesses the androgen-responsive elements in compact chromatin regions, activating a distinct transcription program. This program was highly enriched for genes involved in epithelial-mesenchymal transition and metastasis. Notably, we discovered that SOX9, a critical metastasis driver gene, was a direct target and downstream effector of AR-V7. Its protein expression was dramatically upregulated in AR-V7-induced bone lesions. Moreover, we found that Ser81 phosphorylation enhanced AR-V7's pro-metastasis function by selectively altering its specific transcription program. Blocking this phosphorylation with CDK9 inhibitors impaired the AR-V7-mediated metastasis program. Overall, our study has provided molecular insights into the role of AR splice variants in driving the metastatic progression of CRPC.

Multidisciplinary approach to the management of renal angiomyolipoma with inferior vena cava thrombus and pulmonary embolism: a case report.

Renal angiomyolipoma (AML) is a benign tumor with rare venous extension. We present a case of a patient with renal AML with inferior vena cava (IVC) tumor thrombus and acute pulmonary embolism (PE). A 34-year-old female presented with chest pain. Imaging revealed a 5 cm right renal AML, with tumor thrombus into the renal vein and IVC, and acute left lower lobe PE. Right radical nephrectomy and caval thrombectomy were performed using intraoperative ultrasound. Rarely, these benign tumors generate thrombus with caval extension. The location of IVC thrombus guides surgical planning, which may involve suprahepatic IVC control or cardiopulmonary bypass. Early involvement of a multidisciplinary team with extensive preoperative planning can help achieve successful outcomes.

Speech Intelligibility in Patients with Facial Paralysis.

Background: Patients with facial paralysis often report frustration with communication; however, there are limited data regarding intelligibility deficiencies. Objective: To compare speech intelligibility in patients with severe and non-severe facial paralysis, and in patients with or without synkinesis. Methods: Video and audio data were reviewed retrospectively. Groups were stratified as follows: Group A - severe paralysis (Sunnybrook 0-20) without synkinesis; Group B - non-severe (Sunnybrook >20) paralysis without synkinesis; and Group C - non-severe paralysis with synkinesis. Intelligibility was assessed by lay-people and a speech and language pathologist (SLP) using the Frenchay Dysarthria Assessment Version 2 (FDA-2). A receiver operating characteristic (ROC) curve was used to determine a Sunnybrook cutoff for intelligibility. Results: Eighty cases were reviewed with mean age 55.6, 53.8% female. 25.0% were in Group A, 30.0% Group B, and 45.0% in Group C. Lay-people rated 15.0% and the SLP rated 28.7% as having intelligibility deficiency. An ROC curve demonstrated that patients with Sunnybrook ≤18.5 were more likely to have intelligibility abnormality. Conclusion: Patients with Sunnybrook ≤18.5 are more likely to demonstrate intelligibility deficiency. Clinicians with a more trained ear are more likely to identify intelligibility abnormality compared with lay-people. Those with synkinesis are more intelligible compared with those without it.

High-Grade Pleomorphic Sarcoma in Postauricular Keloid Scar After Surgical Excision and Radiation.

Keloid scars can cause significant morbidity to the patient including substantial cosmetic disfigurement, particularly in the head and neck region. Surgical excision followed by immediate postoperative radiation therapy has been shown to be more effective than single modality treatment. Radiation therapy increases risk for radiation-induced malignancy, though very few cases have been reported in the treatment of keloids. We report the case of a patient with a large postauricular keloid treated with excision and immediate post-operative radiation who developed a high-grade pleomorphic sarcoma in the scar bed. Laryngoscope, 2024.

How to assess nonresponsiveness to vasodilator stress.

Myocardial perfusion imaging (MPI) is a powerful tool for the functional assessment of ischemia in patients with suspected or known coronary artery disease (CAD). Given that the diagnostic accuracy and prognostic value of MPI and post-test management are highly dependent on achieving an adequate stress vasodilatory response, it is critical to identify those who may not have adequately responded to vasodilator pharmacological stress agents such as adenosine, dipyridamole, and regadenoson. Caffeine, a potent inhibitor of the adenosine receptor, is a compound that can affect vasodilatory hemodynamics, result in false negative studies, and potentially alter management in cases of inaccurate test results. Vasodilator non-responsiveness can be suspected by examining hemodynamics, quantitative positron emission tomography (PET) metrics such as myocardial flow reserve (MFR), and splenic response to stress. Quantitative MFR values of 1-1.2 should raise suspicion for nonresponsiveness in the setting of normal perfusion, along with the absence of a splenic switch off. Newer metrics, such as splenic response ratio, can be used to aid in the identification of potential nonresponders to pharmacologic vasodilators.

Endovascular covered stent graft repair by through-and-through snaring of an acute traumatic femoral-femoral arteriovenous fistula following a gunshot wound.

Arteriovenous fistula (AVF) formation after penetrating injury underscores a rare and challenging complication of vascular trauma. Traumatic AVFs have various clinical presentations and reported methods of repair. Although open surgical repair is the most frequently used method of repair, the advancement of endovascular techniques has been increasingly used during the past 3 decades. We report a case of an acute traumatic AVF of the superficial femoral artery and superficial femoral vein from a gunshot wound repaired with a unique endovascular technique involving snaring to establish through-and-through access to allow deployment of a covered stent graft.

Alternative Linkage Chemistries in the Chemoenzymatic Synthesis of Microviridin-Based Cyclic Peptides.

Engineering biosynthetic pathways to ribosomally synthesized and post-translationally modified peptides (RiPPs) offers several advantages for both in vivo and in vitro applications. Here we probe the ability of peptide cyclases to generate trimacrocycle microviridin analogs with non-native cross-links. The results demonstrate that diverse chemistries are tolerated by macrocyclases in the ATP-grasp family and allow for the construction of unique cyclic peptide architectures that retain protease inhibition activity. In addition, cocomplex structures of analogs bound to a model protease were determined, illustrating how changes in functional groups maintain peptide conformation and target binding.

Plastic Surgery Tourism: Complications, Costs, and Unnecessary Spending?

Background: The liability of plastic surgery tourism in patient health and postoperative resource allocation is significant. Procedures completed within the context of medical tourism often lack rigorous quality assurance and provide limited preoperative evaluation or postoperative care. Not only does this jeopardize the patient's well-being, but it also increases the financial burden and redirects invaluable resources domestically through often unnecessary diagnostic tests and hospitalizations. Objectives: This manuscript will examine the complications and associated costs following plastic surgery tourism and highlight unnecessary expenses for patients with outpatient complications. Methods: A retrospective review was conducted of all patients 18 years or older who underwent destination surgery and were seen within 1 year postoperatively in consultation with plastic surgery at our health system between January 11, 2015 and January 7, 2022. Patient admissions were reviewed and deemed necessary or unnecessary after review by 2 physicians. Results: The inclusion criteria were met by 41 patients, of whom hospitalization was deemed necessary in 28 patients vs unnecessary in 13 patients. The most common procedures included abdominoplasty, liposuction, breast augmentation, and "Brazilian butt lift." The most common complications were seroma and infection. Patients deemed to have a necessary admission often required at least 1 operation, were more likely to need intravenous antibiotics, were less likely to have the diagnosis of "pain," necessitated a longer hospitalization, and incurred a higher cost. The total financial burden was $523,272 for all 41 patients. Conclusions: Plastic surgery tourism poses substantial health risks, the morbidities are expensive, and it strains hospital resources.

Analyzing Surgical Technique in Diverse Open Surgical Videos With Multitask Machine Learning.

Objective: To overcome limitations of open surgery artificial intelligence (AI) models by curating the largest collection of annotated videos and to leverage this AI-ready data set to develop a generalizable multitask AI model capable of real-time understanding of clinically significant surgical behaviors in prospectively collected real-world surgical videos. Design, Setting, and Participants: The study team programmatically queried open surgery procedures on YouTube and manually annotated selected videos to create the AI-ready data set used to train a multitask AI model for 2 proof-of-concept studies, one generating surgical signatures that define the patterns of a given procedure and the other identifying kinematics of hand motion that correlate with surgeon skill level and experience. The Annotated Videos of Open Surgery (AVOS) data set includes 1997 videos from 23 open-surgical procedure types uploaded to YouTube from 50 countries over the last 15 years. Prospectively recorded surgical videos were collected from a single tertiary care academic medical center. Deidentified videos were recorded of surgeons performing open surgical procedures and analyzed for correlation with surgical training. Exposures: The multitask AI model was trained on the AI-ready video data set and then retrospectively applied to the prospectively collected video data set. Main Outcomes and Measures: Analysis of open surgical videos in near real-time, performance on AI-ready and prospectively collected videos, and quantification of surgeon skill. Results: Using the AI-ready data set, the study team developed a multitask AI model capable of real-time understanding of surgical behaviors-the building blocks of procedural flow and surgeon skill-across space and time. Through principal component analysis, a single compound skill feature was identified, composed of a linear combination of kinematic hand attributes. This feature was a significant discriminator between experienced surgeons and surgical trainees across 101 prospectively collected surgical videos of 14 operators. For each unit increase in the compound feature value, the odds of the operator being an experienced surgeon were 3.6 times higher (95% CI, 1.67-7.62; P = .001). Conclusions and Relevance: In this observational study, the AVOS-trained model was applied to analyze prospectively collected open surgical videos and identify kinematic descriptors of surgical skill related to efficiency of hand motion. The ability to provide AI-deduced insights into surgical structure and skill is valuable in optimizing surgical skill acquisition and ultimately improving surgical care.

Injectable long-acting ivacaftor-loaded poly (lactide-co-glycolide) microparticle formulations for the treatment of cystic fibrosis: In vitro characterization and in vivo pharmacokinetics in mice.

Optimizing a sustained-release drug delivery system for the treatment of cystic fibrosis (CF) is crucial for decreasing the dosing frequency and improving patients' compliance with the treatment regimen. In the current work, we developed an injectable poly(D,L-lactide-co-glycolide) (PLGA) microparticle formulation loaded with ivacaftor, a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator that increases the open probability of the CFTR anion channel, using a single emulsion solvent evaporation technique. We aimed to study the effect of different parameters on the characteristics of the prepared formulations to select an optimized microparticle formulation to be used in an in vivo pharmacokinetic study in mice. First, a suite of ivacaftor-loaded microparticles were prepared using different formulation parameters in order to study the effect of varying these parameters on microparticle size, morphology, drug loading, encapsulation efficiency, and in vitro release profiles. Prepared microparticles were spherical with diameters ranging from 1.91-6.93 µm, percent drug loading (% DL) of 3.91-10.3%, percent encapsulation efficiencies (% EE) of 26.6-100%, and an overall slow cumulative release profile. We selected the formulation that demonstrated optimal combined % DL and % EE values (8.25 and 90.7%, respectively) for further studies. These microparticles had an average particle size of 6.83 µm and a slow tri-phasic in vitro release profile (up to 6 weeks). In vivo pharmacokinetic studies in mice showed that the subcutaneously injected microparticles resulted in steady plasma levels of ivacaftor over a period of 28 days, and a 6-fold increase in AUC 0 - t (71.6 µg/mL*h) compared to the intravenously injected soluble ivacaftor (12.3 µg/mL*h). Our results suggest that this novel ivacaftor-loaded microparticle formulation could potentially eliminate the need for the frequent daily administration of ivacaftor to people with CF thus improving their compliance and ensuring successful treatment outcomes.

Decision Impact Analysis to Measure the Influence of Molecular Signature Response Classifier Testing on Treatment Selection in Rheumatoid Arthritis.

INTRODUCTION: Clinical guidelines offer little guidance for treatment selection following inadequate response to conventional synthetic disease-modifying antirheumatic drug (csDMARD) in rheumatoid arthritis (RA). A molecular signature response classifier (MSRC) was validated to predict tumor necrosis factor inhibitor (TNFi) inadequate response. The decision impact of MSRC results on biologic and targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) selection was evaluated. METHODS: This is an analysis of AIMS, a longitudinal, prospective database of patients with RA tested using the MSRC. This study assessed selection of b/tsDMARDs class after MSRC testing by surveying physicians, the rate of b/tsDMARD prescriptions aligning with MSRC results, and the percentage of physicians utilizing MSRC results for decision-making. RESULTS: Of 1018 participants, 70.7% (720/1018) had treatment selected after receiving MSRC results. In this MSRC-informed cohort, 75.6% (544/720) of patients received a b/tsDMARD aligned with MSRC results, and 84.6% (609/720) of providers reported using MSRC results to guide treatment selection. The most prevalent reason reported (8.2%, 59/720) for not aligning treatment selection with MSRC results from the total cohort was health insurance coverage issues. CONCLUSION: This study showed that rheumatologists reported using the MSRC test to guide b/tsDMARD selection for patients with RA. In most cases, MSRC test results appeared to influence clinical decision-making according to physician self-report. Wider adoption of precision medicine tools like the MSRC could support rheumatologists and patients in working together to achieve optimal outcomes for RA.

A paradoxical internal hernia at Brolin's anti-obstruction stitch following Roux-en-Y gastric bypass: a case report.

Internal hernias are a rare but morbid complication following Roux-en-Y gastric bypass surgery. The incorporation of Brolin's anti-obstruction stitch has historically demonstrated a significant reduction in the incidence of internal hernias following Roux-en-Y gastric bypass. We present an ironic and unique case of a patient with small bowel herniation into a defect between Brolin's stitch and the stapled closed common enterotomy of the jejunojejunostomy and technical considerations to decrease internal hernias at this site in the future.

MicroRNA Expression Profile in Early-Stage Breast Cancers.

BACKGROUND: Breast cancer is one of the leading causes of cancer deaths in women. Early diagnosis offers the best hope for a cure. Ductal carcinoma in situ is considered a precursor of invasive ductal carcinoma of the breast. In this study, we carried out microRNA sequencing from 7 ductal carcinoma in situ (DCIS), 6 infiltrating ductal carcinomas (IDC Stage IIA) with paired normal, and 5 unpaired normal breast tissue samples. We identified 76 miRNAs that were differentially expressed in DCIS and IDC. METHODS: Additionally, we provide preliminary evidence of miR-365b-3p and miR-7-1-3p being overexpressed, and miR-6507-5p, miR-487b-3p, and miR-654-3p being downregulated in DCIS relative to normal breast tissue. We also identified a miRNA miR-766-3p that was overexpressed in early-stage IDCs. The overexpression of miR-301a-3p in DCIS and IDC was confirmed in 32 independent breast cancer tissue samples. RESULTS: Higher expression of miR-301a-3p is associated with poor overall survival in The Can-cer Genome Atlas Breast Cancer (TCGA-BRCA) dataset, indicating that it may be associated with DCIS at high risk of progressing to IDC and warrants deeper investigation. CONCLUSION: We also analyzed competing endogenous networks associated with differentially expressed miRNAs and identified LRRC75A-AS1 and MAGI2-AS3 as lncRNAs that potentially play an important role in early-stage breast cancers.

Operative technique for a successful laparoscopic en-bloc resection of gastrogastric fistula following roux-en-Y gastric bypass.

Gastrogastric fistulas are rare complications following Roux-en-Y gastric bypass surgery and are characterized by a fistulous connection between the gastric pouch and the remnant stomach. The presentation is often variable and a high-index of suspicion must be maintained for accurate and timely diagnosis. In this case report, we provide a detailed review of the technical steps taken to successfully resect a gastrogastric fistula en-bloc laparoscopically with an unremarkable post-operative course.

The Utility of the Paramedian Forehead Flap in Lower Eyelid Reconstruction.

BACKGROUND: Malignant cutaneous eyelid tumors account for approximately 10% of all cutaneous cancers. Like other cancerous skin lesions, treatment commonly involves excision with wide margins, requiring tissue reconstruction. The use of the paramedian forehead flap (PMFF) has been described for reconstruction of the medial and upper eyelid, but literature is lacking for its use in lower eyelid anterior lamella reconstruction. We present a case series of patients who underwent reconstruction of lower eyelid defects using the PMFF. CASE PRESENTATIONS: We present 2 patients who underwent reconstruction of lower eyelid defects using the PMFF surgical technique. The patients had previous history of lower lid repair with other reconstructive methods because of cancerous eyelid lesions. In addition, both received adjuvant radiation therapy, which led to development of ectropion. Postoperative signs, symptoms, and photographs were collected to monitor outcomes. MANAGEMENT AND OUTCOMES: Reconstructions were performed by the collaborative efforts of a facial plastic reconstructive surgeon and oculoplastic surgeon using a staged PMFF approach. Postoperatively, both patients had significant improvement in ophthalmologic symptoms, particularly ectropion and lagophthalmos. At their most recent follow-up visit, they were satisfied with their functional and aesthetic outcomes. CONCLUSION: The PMFF may be safely used to reconstruct defects of the lower eyelid anterior lamella. In this study, the PMFF has proven to be an excellent option for patients with complications after previous lower eyelid reconstructions or history of radiation therapy. Overall, the PMFF should be considered as part of the surgeon's reconstructive ladder when addressing lower eyelid defects.

Surgical management of congenital malrotation presenting in adulthood.

Intestinal malrotation is characterised by positional and congenital fixation abnormalities resulting from a failure in embryonic development in the normal 270° rotation around the axis of the superior mesenteric artery. Intestinal malrotation is primarily thought to affect neonates with an incidence of 1 in 500, however, only 1 in 6000 live births are symptomatic, and these usually present within the first month of life in 40% of cases and within the first year in over 5% of cases as an obstructive pathology or volvulus. In adults, however, the incidence has been documented at 0.2%. These patients usually present with postprandial symptoms that are intermittent such as bilious emesis, abdominal pain and malabsorption. Rarely, adults with congenital malrotation may present with acute obstruction due to volvulus, however, less than 100 adult cases are described in the literature. A high index of suspicion is required to identify cases of malrotation in the adult patient which leads to delays in diagnosis and therefore increases in morbidity can be seen.

A case report of acute appendicitis complicated by pylephlebitis: medical and surgical management.

Pylephlebitis is a suppurative thrombus of the portal vein and/or its branches secondary to an intra-abdominal infection. Acute appendicitis is the most common cause of emergency operation in general surgery and is typically treated with antibiotics and timely appendectomy with minimal adverse outcomes (Ferris M, Quan S, Kaplan BS, et al. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg 2017;266:237-41 and Poon S, Lee J, NG KM, Chiu GWY, et al. The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance. WJES 2017;12:46). Unfortunately, the identification of pyelephlebitis is difficult to make due to its nonspecific clinical presentation and can result in significant morbidity or mortality if not appropriately treated. Certain laboratory derangements and positive intra-abdominal imaging combined with a high index of suspicion can make the diagnosis. Treatment involves broad-spectrum antibiotics, anticoagulation, and source control of the primary nidus of infection. Our case presentation follows the successful clinical course of a young male diagnosed with acute appendicitis complicated by pylephlebitis. He was treated with antibiotics and anticoagulation followed by interval laparoscopic appendectomy with consequential resolution of thrombus on subsequent cross-sectional imaging.