Mammillary fistula revisited: Implications for immediate breast reconstruction.

We present two patients with inverted nipples who underwent bilateral nipple-sparing mastectomies (NSM) with immediate placement of tissue expanders with acellular dermal matrix (ADM). Both were complicated by postoperative infection and developed mammillary fistulae from the nipple into the breast capsule, and eroding through the ADM. For the first time, we report inverted nipples as a risk for the iatrogenic formation of mammillary fistulae and their infectious implications after NSM.

Lateral Branch of the Thoracodorsal Nerve (LaT Branch) Transfer for Biceps Reinnervation.

In cases of significant upper extremity trauma, the thoracodorsal nerve is a reliable secondary option for the restoration of elbow flexion. In all previous descriptions, however, the entire nerve is transferred. We describe a case utilizing the lateral thoracodorsal nerve (LaT) branch for biceps reinnervation with an associated cadaver study. Transfer of the LaT branch to the biceps branch was performed on a patient who had sustained a traumatic brachial plexus injury that left him without elbow flexion. Also, 4 cadavers (8 upper extremities) were dissected to identify the bifurcation of the thoracodorsal nerve and confirm the feasibility of transferring the LaT branch to the biceps motor branch. Axon counts of the thoracodorsal proper, LaT branch, musculocutaneous proper, and the biceps branch were also obtained. A bifurcation of the thoracodorsal nerve was present in all cadaver specimens, with an average distance of 7.5 cm (range, 6.2-9.8 cm) from the insertion of the latissimus dorsi muscle. Axon counts revealed a donor-to-recipient ratio of 0.85:1. Follow-up of our patient at 1 year showed improvement of elbow flexion manual muscle testing grade from 0 to 4/5. Furthermore, electromyography at 1 year confirmed biceps reinnervation and showed normal readings of the latissimus compared with preoperative electromyography. Transfer of the LaT branch is a viable and minimally morbid option for biceps reinnervation after traumatic branchial plexus injury. Further follow-up of our patient and larger prospective studies are needed to understand the true potential of this nerve transfer.

Cadaveric Study of a Z-Plasty Modification to the Moberg Flap for Increased Advancement and Decreased Morbidity.

BACKGROUND: The Moberg advancement flap is a well-established tool to provide sensate, vascularized tissue for thumb reconstruction. Modifications providing additional length have been described, but no studies have examined how much additional advancement can be achieved consistently, and at what cost. The authors hypothesized that Z-plasty modification at the base of the Moberg flap would allow additional advancement compared with the traditional technique, and maintain primary closure of the donor-site and avoid additional morbidity. METHODS: Standard Moberg flaps were performed and advancement was measured on 20 cadaver specimens. Ten flaps were then modified with the O'Brien technique of incising proximally and skeletonizing the neurovascular bundles. The other 10 flaps were modified with Z-plasties at the base of the thumb. Differences in distance of advancement were compared, as was the ability to primarily close donor sites. RESULTS: Average advancement for Moberg flaps was 7.3 ± 1.2 mm, compared with 15.0 ± 2.5 mm for the O'Brien modification (p < 0.01) and 11.3 ± 1.7 mm for the Z-plasty modification (p < 0.01). CONCLUSIONS: Although the O'Brien modification allows approximately 50 percent further advancement than the Z-plasty modification compared with the standard Moberg flaps, the increase correlates to a large area of exposed neurovascular bundles at the volar base of the thumb, which requires secondary coverage. However, all Z-plasty donor-sites could be closed primarily. Primary closure of all donor sites will decrease healing time, wound complications, digital nerve sensitivity, and cosmetic appearance. This study is the first to show a significant increase in Moberg flap advancement using Z-plasty lengthening at the thumb base while avoiding any increased morbidity.

Anterior sacral meningocele presenting as constipation.

Anterior sacral meningocele (ASM) is a rare form of spinal dysraphism in children. Usually asymptomatic, it can present as constipation, urinary problems or rarely neurological symptoms. High index of suspicion with careful clinical examination is necessary to make early diagnosis. Magnetic resonance imaging is the investigation of choice. We describe a successfully managed young child with ASM associated with rib and vertebral defects.

Orthotopic hind-limb transplantation in rats.

Composite tissue allotransplantation (CTA) now represents a valid therapeutic option after the loss of a hand, forearm or digits and has become a novel therapeutic entity in reconstructive surgery. However, long term high-dose multi-drug immunosuppressive therapy is required to ensure graft survival, bearing the risk of serious side effects which halters broader application. Further progression in this field may depend on better understanding of basic immunology and ischemia reperfusion injury in composite tissue grafts. To date, orthotopic hind limb transplantation in rats has been the preferred rodent model for reconstructive transplantation (RT), however, it is an extremely demanding procedure that requires extraordinary microsurgical skills for reattachment of vasculature, bones, muscles and nerves. We have introduced the vascular cuff anastomosis technique to this model, providing a rapid and reliable approach to rat hind limb transplantation. This technique simplifies and shortens the surgical procedure and enables surgeons with basic microsurgical experience to successfully perform the operation with high survival and low complication rates. The technique seems to be well suited for immunological as well as ischemia reperfusion injury (IRI) studies.

Pathways change in expression during replicative aging in Saccharomyces cerevisiae.

Yeast replicative aging is a process resembling replicative aging in mammalian cells. During aging, wild-type haploid yeast cells enlarge, become sterile, and undergo nucleolar enlargement and fragmentation; we sought gene expression changes during the time of these phenotypic changes. Gene expression studied via microarrays and quantitative real-time reverse-transcription polymerase chain reaction (qPCR) has shown reproducible, statistically significant changes in messenger RNA (mRNA) of genes at 12 and 18-20 generations. Our findings support previously described changes towards aerobic metabolism, decreased ribosome gene expression, and a partial environmental stress response. Our findings include a pseudostationary phase, downregulation of methylation-related metabolism, increased nucleotide excision repair-related mRNA, and a strong upregulation of many of the regulatory subunits of protein phosphatase I (Glc7). These findings are correlated with aging changes in higher organisms as well as with the known involvement of protein phosphorylation states during yeast aging.