Identification and functional analyses of a novel FOXL2 pathogenic variant causing blepharophimosis, ptosis, and epicanthus inversus syndrome.

AIM: To discover the molecular pathogenic basis of the blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES), and to predict the clinical subtype according to in vitro experiments, which is significant to the prognosis. METHODS: A 3-year-old sporadic female patient with typical clinical manifestations of BPES was enrolled. The coding region of forkhead box L2 (FOXL2) gene was sequenced, and the functional assays were performed in vitro by Western blotting, subcellular localization experiment, luciferase reporter assay, and quantitative real-time polymerase chain reaction. RESULTS: A novel FOXL2 point pathogenic variant (c.274G>T) was detected, resulting in a truncated protein (p.E92*). Functional studies demonstrated that the FOXL2 pathogenic variant induced the subcellular mislocalization and the abnormal transcriptional activity on promoters of the steroidogenic acute regulatory protein (StAR or STARD1) gene and the odd-skipped related 2 transcription factor (OSR2) gene. CONCLUSION: A novel pathogenic variant is identified to expand the spectrum of the known FOXL2 mutations. The in vitro experiments provide reference data and more insights to the molecular pathogenesis of BPES. The predicted high risk of ovarian insufficiency makes it significant for the patient enrolled to have further follow-up and therapy concerning female endocrinology.

[Repair of scars in submaxillary region using expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein].

OBJECTIVE: To study the feasibility of applying expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein (expanded forehead axial flap with double pedicles in brief, EFAF-DP) in repairing scars in submaxillary region. METHODS: Sixteen patients with mandibular scars hospitalized in Department of Burns and Plastic Surgery of the First Hospital Affiliated to Fuzhou General Hospital in Nanjing Military Area Command from July 2005 to December 2009 were repaired with EFAF-DP. The operation consisted of 3 stages. Before operation, the location and course of superficial temporal arteries and veins (STAV) and their frontal and parietal branches were identified with Ultrasonic Doppler blood flow detector. In stage I, STAV were dissected from the frontalis muscle as a pedicle to form a skin soft tissue space to hold the dilator of a proper size. In stage II, after gradual dilation by repeated filling with saline, the dilator was removed. EFAF-DP was dissected to repair mandibular scar. Donor site was closed with sutures. In stage III, flap pedicles were divided and pruned. RESULTS: Flap sizes ranged from 25 cm × 6 cm to 33 cm × 16 cm. The duration of dilation was 3-5 months, with 3.6 months in average. Ten patients underwent the operation of EFAF-DP transplantation and cervical skin dilatation. All flaps survived with healing of wounds. Disorder of venous return at the distal end of one flap was seen after second stage surgery, and it was corrected after comprehensive treatment including relieving spasm and improving venous return. Donor site wounds healed with normally grown hair without cicatricial alopecia along the hairline. Few hairs grew around mandible in one female patient out of the three (no hair grew on flaps of other two patients). This female patient and two male patients requesting for beard plasty received laser depilation treatment 1 to 3 months after discharge, with good result. Other male patients received no special treatment for their beard, and they shaped their beard with shaver. Sixteen patients were followed up for 6 to 24 months, and the shape of the flaps and beard (excluding female patients) were satisfactory with good appearance, satisfactory skin color and texture. The mobility of neck was obviously improved. CONCLUSIONS: EFAF-DP provides bigger areas of a thin flap besides promoting vascularization of new vessels of flap. Extra expanded skin can be directly sutured at the fringe of hairline, which makes skin grafting unnecessary, and decreases the incidence of secondary deformity in donor sites. Some hair carried by the flaps can be directly used for beard reconstruction after rotation to help the male patients have a better appearance.

[Repair of cervicofacial scar by forehead expansive skin flap double-pedicled with superficial temporal vessels].

OBJECTIVE: To explore the clinical efficacy of using forehead expansive skin flap double-pedicled with superficial temporal vessels for repairing male cervicofacial scar. METHODS: From July 2005 to June 2009, 13 male patients with an average age of 27 years old (range: 21 - 38) were operated by the above method. The scar-repairing area was from 14 cm × 5 cm to 32 cm × 15 cm. The procedure was carried out in three stages. Firstly, ultrasound Doppler was used to detect and mark the location and orientation of superficial temporal artery. A proper cavity was created under the forehead muscle and then the appropriate expander embedded through the scalp incision. The expander was expanded first by injecting normal saline at 1 or 2 weeks post-operation. After that, the injection was repeated by 3 or 5 days. The volume ratio of injection to expander was (1.5-3.5):1. Secondly the forehead expansive skin flap was designed with proper hair follicle scalp pedicled by bilateral superficial temporal artery when the expansion was completed. After removal of the expander, the rectangle expansive skin flap with hair follicle scalp was transferred through the double pedicle. The cervicofacial scar was excised according to the size of the transferred expansive skin flap (25 cm × 6 cm to 32 cm × 9 cm). And the flap was adjusted with hair follicle scalp to the middle of the chin area in order to obtain the normal beard appearance. Donor site were closed directly. Thirdly, the pedicle skin flap were cut and restored after one month. RESULTS: The volume expanded for each expander ranged from 420 to 800 ml (mean: 660). The average expansion time was 4 months (range: 3 - 5). All flaps survived well. Donor site were closed directly. Both chin and beard looked normal. CONCLUSIONS: Repairing hypertrophic scar and reconstructing beard in cervicofacial area with forehead expansive skin flap pedicled by bilateral superficial temporal artery is a valuable and safe method. The donor site is scarless. And the reconstructed chin and beard are normal both functionally and aesthetically.

[Plastic surgical management of large cicatricial scalp alopecia].

OBJECTIVE: To investigate the proper ways to manage a large cicatricial scalp alopecia. METHODS: Based on the location, size and condition of the scarring lesions, 218 patients with 20 - 75% scarring alopecia were selected and treated with either dense-packing hair grafting technique (136 cases) or tissue expansion (82 cases). There were 209 in burn, 5 in avulsed injury and 4 in tumor excision. The lesions with thick, stable scars in the frontal or/and temporal areas undergoing either hair grafting or tissue expansion process as desired by the patients. In addition, the alopecia in an unstable scar on the skull, with skull defect under the lesion and the lesion involved in the back of the head was only treated with tissue expansion. The hair-grafting technique was carried out by harvesting a scalp strip from the back of the head, then dividing it into a series of 1 - 3 hair grafts and finally implanting them into the prepared recipient holes of the lesion with a desired hair direction. Ten areas with 1 cm(2) size in 10 patients were randomly selected to examine the hair survival over 8 months post-operation. Tissue expansion was performed by firstly positioning a tissue expander in the subgaleal pocket of the scalp and serially inflating it with normal saline in 5 - 7 days intervals for about 3 months. Thereafter, an expanded scalp flap was designed, with the combination of advancement and rotation flap transplantation principles, to be transferred to the recipient site after lesion removal. RESULTS: In patients with hair-grafting technique, hair density reaching 60 - 80 hairs/cm(2) per session. Over 8-months following-up, the grafted hairs grew good with 98% hair survival. Forty-five patients with 20% - 30% scalp hair loss were reaching very satisfactory results with only one session while 91 patients with 31% - 50% hair loss were needed a second session to improve their appearance. In those with tissue expansion, 56 patients with 20% - 50% scalp loss were managed in one session and 26 patients with 51% - 75% scalp loss needed secondary tissue expansion. All of the expanded hair-bearing flaps survived well with only minimal complications (9.8%) of the infective dome explosion in 3, slight skull depression in 2, seroma in 5 and early infection in 1. CONCLUSION: Either hair grafting or tissue expansion is proven as a safe and effective technique for restoration of large cicatricial scalp alopecia. The former technique could be of benefits to simple, mini-surgical procedure, natural hair growth and good for lesion size under 30%. And the letter technique shows wider clinical indications, especially for the patients with unstable scar, skull defect under lesion and lesion over 50%. But the obvious drawbacks are multi-clinic visiting, disfigurement and long-term procedures.

[The treatment of cicatricial alopecia after burn with the technique of synchronously perforating and transplanting hair follicular-units].

OBJECTIVE: To study the effect of the technique of synchronously perforating and transplanting hair follicular-units in the treatment of cicatricial alopecia after burn. METHODS: One hundred and sixty-six patients with 217 bald scar areas after burn were treated with above-mentioned technique from January 2002 to April 2008. Scalp strips, with conforming the necessity for grafting, were harvested from the occipital or temporal region. A series of follicular-units, each composing 1 - 3 hairs, were dissected from the strips under microscope or magnifying glass. Size-matching micro-slots were made in the scarred recipient area with 16 - 20 G needles to accept the grafts. The prepared follicular-unit was synchronously implanted into the bottom of the micro-slot as the needle being withdrawn. Patients who were not satisfactory with the density of hairs after I stage surgery underwent II stage surgery a half year later. Ten recipient areas with clear boundary in 10 patients were optionally chosen to observe the density of follicular-units and hair amount with naked eyes after I stage surgery. Survived transplanted hairs in above-mentioned 10 areas were counted to calculate hair survival rate at follow-up. Patients' postoperative satisfaction ratings were surveyed with questionnaire. RESULTS: In one half of the patients, treatment was finished after I stage surgery, the other one half received 2 stages of surgery. The follicular-unit density reached 15 - 25 grafts/cm(2) with 40 - 70 hairs/cm(2) after I stage surgery. All patients were followed up for over 8 months. Grafted hairs grew well in a natural way. 96.5% mean hair survival rate was observed in the 10 recipient areas. From patients who received only I stage surgery, 61 patients (73.5%) were very satisfactory and 22 patients (26.5%) satisfactory with the results. From the other half of patients, 76 patients (91.6%) were very satisfactory and 7 patients (8.4%) satisfactory with the results. CONCLUSIONS: The technique of perforating and transplanting follicular-unit hair synchronously is safe and effective with less surgery-induced injury and less bleeding. Hairs transplanted on cicatricial alopecia area with this technique grow well with high survival rate.

[Clinical application of the scapular free flap extended to the upper arm].

OBJECTIVE: To apply the scapular free flap extended to the upper arm for resurfacing the face and neck, as well as the upper lip in one stage. METHODS: The scapular free flap was designed with extended portion to the posterior and interior part of the upper arm. Then the free flap was transferred to resurface the face and neck with the routine portion and to resurface the upper lip with the extended portion. RESULTS: 6 cases with extensive upper lip, facial and cervical burn scar were treated with the extended scapular free flaps. The flap size ranged from 22 cm x 11 cm to 40 cm x 9.5 cm (36.57 cm x 10.20 cm in average) for the routine portion and from 7 cm x 4 cm to 12 cm x 4 cm (10.32 cm x 3.67 cm in average) for the extended portion. All flaps survived completely. CONCLUSIONS: There are direct communicating branches ("choke vessel") between the circumflex scapular artery (CSA) and the posterior humeral circumflex artery (PHCA). When the blood supply of PHCA is cut off, the CSA can provide blood supply through the communicating branches to the upper arm skin area previously nourished by PHCA. So the blood supply of the extended portion of the scapular free flap is not only from the branches of CSA, but also from the direct communicating branches between the CSA and PHCA. The extended scapular free flap has a reliable blood supply and can be applied to construct the facial and cervical scar contraction with the extended portion to resurface the upper lip. The satisfactory result can be expected.

[The penis prolongation and augmentation combined with autologous granular fat injection and silicone implantation].

OBJECTIVE: To prevent the retraction of the penis after prolongation and augmentation. METHODS: After all the superficial and part of the deep suspensory ligament amputation, we implanted the silicon sheet (the length 2.3-3.6 cm, the width 1.5-2.5 cm, the thickness 2-3 mm) and injected autologous granular fat (30-48 ml) into penis. RESULTS: 16 patients (age 22-63 years, averagely 38 years) underwent this kind operation, the prolongation length is 1.8-5.1 cm, the average was 2.91 cm, the increased diameter of penis was 0.6-1 cm, the average is 0.85 cm, the following period is 3 months to 2 years. The results are satisfactory with the penis retraction less than 8%, and less than 10% decrease in diameter. CONCLUSIONS: This method is an ideal way of the penis prolongation and augmentation, the implantation of the silicon sheet is effective way to prevent the retraction of the penis.

[Repair of the facial defects using the expanded induced prefabricated skin flap of the retroauricular and mastoid process region based on the superficial temporal vascular bundle].

OBJECTIVE: To provide an ideal method for flap prefabrication. METHODS: The superficial temporal fascial flap has been elevated based on the superficial temporal vessels during the first-stage procedure. A subcutaneous tissue pocket with appropriate site was formed in the retroauricular and mastoid process region. The fascial flap was transferred into the pocket and fixed properly. The tissue expander was placed under the fascial flap. When the expanding process has been finished, the expander was removed and the expanded induced prefabricated skin flap of the retroauricular and mastoid process region pedicled on the superficial temporal vascular bundle was elevated and transferred to repair the facial skin defect. RESULTS: There were nine cases in the group. Facial defects after resection of the melanotic nevus was repaired in 2 cases and facial defects after resection of the facial haemangioma and scar were repaired in 2 and 5 cases respectively. Pedicle length of the superficial temporal fascial flap was ranged from 5.5 cm to 7 cm (mean length 6.2 cm). The size of the fascial flaps was ranged from 4 cm x 3 cm to 7 cm x 7 cm (mean size 5.7 cm x 4.9 cm). The size of the prefabricated skin flaps was ranged from 5 cm x 5 cm to 8.0 cm x 7.5 cm (mean size 6.4 cm x 6.1 cm). The average time of the tissue expansion process is 16.1 weeks. All flaps survived postoperatively and the donor sites of the flaps were appropriated directly in 5 cases. The split-thickness skin grafting was used to recover the donor site defects in 4 cases. CONCLUSIONS: The superficial temporal fascial flap owns the following advantages: the vascular pedicle is much longer and vascular supply is plentiful, and it is convenient to transfer. Meanwhile, the skin of the retroauricular and mastoid process region is most similar to that of the face in texture, color and depth. For the patients selected strictly, the technique mentioned above is somewhat an ideal method for facial defect repair.

[A "silicone suture" technique aided to scalp reduction for the treatment of scarring alopecia].

OBJECTIVE: To evaluate a "silicone suture" technique for enhancing the effect of scalp reduction. METHODS: Under the local anesthesia, when an incision was made in the midline of the lesion, the dissection was carried out underlying the sub-galea on both sides of the lesion, as far as the width of the lesion. A 3 mm silicone suture in diameter was placed in the galea beyond the lesion. After the first suture bite was anchored in the tissue at one end, the suture device was continued across the midline in such a way as a running, buried, horizontal mattress suture and it was brought out to the skin surface through the deep tissue at the another end of the lesion with a locker. The extra-tissue of the lesion was then excised and the wound was directly closed in layers. After one week of the operation, the silicone suture was gradually tightened in 2-3 times a week for about 3-5 weeks, until both sides of the lesion were approximately closed. The device was there after removed and the wound was directly closed in layers after the scar was excised. RESULTS: Between October of 1999 and March of 2006, 12 scarring-scalp patients, 7 males and 5 females, were treated by using the silicone suture device without complications. The excised defects were 5-10.5 cm in width. The stretching period was 26.4 days in mean. With the following-ups over 3 months, no hypertrophic scar and widening scar cases appeared. CONCLUSIONS: The silicone suture as an alternative device for tissue extension could be a safe, simple, effective and economical device. It could significantly enhance the efficiency of scalp reduction.

[An animal model of venous congested flap for long-term microcirculation study].

OBJECTIVE: To set up a venous congested flap model to study the mechanism of necrosis through long-term microcirculation observation. METHODS: A specially deviced chamber was assembled to one side of the ears in an adult white rabbit, about 7 approximately 10 days after the operation the congested flap model was made and the microcirculatory status of the flap was dynamically observed under a vivo-microscope for a long time. RESULTS: The venous crisis phenomenon of flap was well studied and the microcirculation of the flap was observed carefully, finally the variational rule of the congestion flap microcirculation was made clear. CONCLUSIONS: The model could well simulate the venous crisis flap in clinic, and the microcirculation could also be observed for a long time.

[An experimental study on the culture of human oral mucosa epithelium using autologous serum].

OBJECTIVE: To investigate the biological properties of cultured human oral mucosa epithelium using autologous serum in order to provide a new material for tissue engineering urethra. METHODS: The cultured oral mucosa epithelium was respectively transplanted beneath the skin, above the deep fascia and in the wound of the athymic mice. The specimens were taken at 2, 3, 4, and 6 weeks posttransplantation, and processed for (1) immunofluorescence anti-HLA staining to determine graft acceptance, and (2) anti-human IV collagen and antihuman laminin immunohistochemical staining procedures to indicate the basement membrane formation. RESULTS: All the grafts survived and grew very well. The grafts were positive to anti-HLA. Collagen type IV and laminin were detected at the dermo-epidermal junction in all groups from day 14, and increasing in density up to day 21. CONCLUSIONS: he cultured human oral mucosa epithelium by autologous serum could develop an excellent functional epithelium tissue, which would be used to reconstruct urethra and repair wound.

[Breast reconstruction with multiple miniprostheses].

OBJECTIVE: To evaluate a new technique for breast reconstruction with multiple miniprostheses, METHODS: Each silicone miniprosthesis(10 approximately 15 ml) was implanted one by one beneath the prepared muscle pocket until the desired volume was achieved. RESULTS: Seven patients were treated with the above mentioned technique, including five after gland fibroadenoma excision, one hemangioma excision and one reduction mammoplasty. The results were satisfactory. CONCLUSION: The above mentioned technique with the miniprostheses may be another good way for breast augmentation and breast reconstruction with many advantages such as smaller incision, easy intraoperative assessment of the ideal size of the breast, easy handling the technique, perhaps low incidence of capsular contracture.

[Experimental study on inhibition of skin graft contraction with papaverine cream].

OBJECTIVE: To evaluate the effect of exteral use of papaverine cream on enhancement of skin graft. METHODS: Five mini-pigs were used for the study. 20 full-thickness wounds were created on the back of each animal. Along the midline of the abdomen, a 40 cm x 2 cm full-thickness skin graft was harvested and the wound sutured.The full-thickness graft was prepared and trimmed to 2 cm x 2 cm of 0.6 mm thickness split-skin grafts, which were transplanted to each wound with tie-over bolsters. The sutures were removed 2 weeks after the operation. Twelve pairs of 100%-survived skin grafts were selected and divided into group A (the left side) and group B (the right side), with each pair locating on the same and opposite position. From the day of suture removal, 2% papaverine cream was used to group A while plain cream was used to group B. The grafts were measured and observed for healing condition at the time of suture removal and the first, second, third, fourth, fifth, and sixth month. The surface area of the graft was measured and the shrinking ratio was calculated. After the animals were killed at the sixth month, samples of the skin grafts were taken and processed with 10% formalin, routine paraffin wax and Hematoxylin-eosin staining. The tissue structure was observed and the results were analyzed statistically. RESULTS: The grafts in two groups did not have significant differences at the time of suture removal. Observations from the first to the sixth month showed that the two groups had significant differences in skin graft contracture and histological changes. HE stains demonstrated that the skin grafts in group A had less fibroblasts, more microvessels and orderly-arranged collagenous fibers. CONCLUSIONS: External use of papaverine cream can inhabit the contraction of skin grafts. It is a safe, effective, simple, and reliable method,which has the advantages of easy delivery,cheapness, less injury and infection,and no side effects.