En-bloc excision of sacral squamous cell carcinoma with immediate reconstruction.

Sacral squamous cell carcinoma is an uncommon condition that may arise in scars following burns or in chronic wounds, such as an untreated pilonidal cyst. The aim of the present technical note is to describe a surgical technique aimed at minimizing local recurrence rates by en-bloc resection as well as providing immediate plastic reconstruction: 1. right-sided extended vertical rectus abdominis myo-cutaneous (VRAM) flap; 2. abdomino-perineal excision of the rectum with end colostomy; 3. en-bloc excision of the mass inclusive of gluteus maximus muscles and distal sacrectomy; 4. sacrectomy defect covered with VRAM flap; 5. bilateral gluteal defects covered with single-layer dermal substitute of bovine collagen and elastin hydrolysate followed by immediate split-thickness skin grafting from bilateral thigh donor sites, and negative pressure wound therapy dressings. This approach resulted in a favorable outcome at 2-year follow-up in a male patient presenting with a large locally advanced sacral squamous cell carcinoma involving the external anal sphincter muscle.

Surgical Management of the Internal Nasal Valve: A Review of Surgical Approaches.

BACKGROUND: Nasal valve collapse is relatively common with a lifetime prevalence of up to 13%. Etiologies include prior rhinoplasty, other surgical procedures, facial paralysis, congenital defects, trauma, and aging. Internal nasal valve collapse leads to impairment of nasal breathing, which significantly disturbs quality of life. Many approaches to increase the cross-sectional area of the internal nasal valve have been described. RESULTS: The main categories reviewed in this article are cartilage grafting, implants, and suture suspension techniques. Cartilage grafting techniques include alar batten graft, butterfly graft, spreader graft, autospreader graft, and alar composite graft. The implant technique includes the titanium butterfly implant. The suspension techniques included are the transconjunctival approach, Mitek bone anchor, flaring suture, lateral pull-up, and piriform rim suspension. Surgeons must carefully consider functionality, cosmesis, and technical difficulty when selecting an approach. DISCUSSION: We review indications, general approach, benefits, and considerations for a number of available techniques to help surgeons decide what approach might be best suited to the individual patient. 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.

Facial nerve transfer for facial reanimation with parotidoplasty approach.

BACKGROUND: Facial paralysis has a profound impact on quality of life in affected individuals, primarily through loss of verbal and nonverbal communication. Common facial nerve reanimation techniques include coaptation to the masseteric or hypoglossal nerve. Most techniques require nerve grafts to achieve a tension-free neurorrhaphy. Our report aims to show a surgical adaption to current facial reanimation procedures using a partial parotidoplasty approach in order to avoid challenges caused by interpositional nerve grafts through primary neurorrhaphy. PATIENTS AND METHODS: The modified surgical approach was performed on four patients, aged 30-67. Length of paralysis ranged from 6 to 13 months. Cause of paralysis included one patient with Bell's palsy in one patient, prior surgery in two patients, and traumatic fracture in the remaining patient. A modified Blair approach is used to expose the parotid capsule. The facial nerve is dissected proximally toward the stylomastoid foramen and distally toward the masseter. The parotid gland substance is sectioned overlying each branch of the facial nerve using ultrasonic dissection or hemostatic scalpel, allowing mobilization of the proximal segment and upper and lower divisions of the facial nerve. The superficial lobe of the parotid is preserved in most cases. The House-Brackmann (H-B) functional scale was used to assess facial nerve function pre- and post-operatively. RESULTS: All patients showed H-B score V or greater prior to reanimation. Follow-up was conducted at 3-, 6-, and 12-months in all patients with resultant improvement of H-B scores of I in three patients and II in the remaining patient. Only one complication was noted, with one patient developing a right postauricular hematoma that was adequately managed without sequelae. All remaining patients experienced an uncomplicated post-operative course. CONCLUSION: Our modified approach to facial nerve reanimation works well with a planned parotidoplasty allowing for successful reanimation outcomes without the need for interpositional grafting. This technique may be considered in masseteric and hemi-hypoglossal nerve transfers for the reinnervation of facial muscles.

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review.

BACKGROUND: Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS: The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS: This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS: This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Atypical Spindle Cell Lipomatous Lesion Resected From Patient With History of CLL.

Atypical spindle cell lipomatous neoplasm, also known as well-differentiated spindle cell liposarcoma, represents a newly discovered entity of adipocytic tumors. Recent research has shown this tumor variant to be more related to spindle cell lipoma, rather than the originally hypothesized atypical lipomatous tumor spectrum. Here we present a case of a 58-year-old man with a history of chronic lymphocytic leukemia with an enlarging mass on the posterior left shoulder, initially hypothesized to be a benign lipoma. However, magnetic resonance imaging showed a large, multiseptated, heterogeneous mass concerning for soft tissue sarcoma. After resection, pathologic analysis showed cells closely resembling spindle cell lipoma, with additional cellular and fascicular zones containing lipoblasts and mitotic figures. Molecular analysis showed no MDM2 amplification. This lack of amplification indicates this tumor is distinctly different from an atypical lipomatous tumor, which characteristically displays MDM2 amplification. However, tumor expression of RB1 was normal. The majority of atypical spindle cell lipomatous neoplasms are associated with RB1 deletions. We conclude that we have a unique example of an atypical spindle cell lipomatous tumor.

Innervated Pedicled Gracilis Flap for Dynamic Abdominal Wall Reconstruction.

Abdominal wall reconstruction for full-thickness defects is a challenging procedure that usually requires the use of flaps. The gracilis flap is known to be used in hernia repair in which the abdominal muscles are still intact, but there are no reports in literature describing the use of an innervated gracilis for dynamic abdominal wall reconstruction after tissue loss due to severe trauma. We present a surgical technique in which the gracilis is harvested preserving the neurovascular pedicle, then tunneled underneath the adductor longus to cover the lower abdominal defect and provide it with basal muscle tone without tension on the pedicle. This results in restored integrity of the musculofascial abdominal wall and dynamic muscle function and support. The gracilis flap has been proven to be useful and versatile in reconstructive surgery with great potential in abdominal wall reconstruction having minimal donor-site morbidity and hernia recurrence risk.

Examining the Role of Antimicrobial Irrigation and Capsular Contracture: A Systematic Review and Meta-analysis.

PURPOSE: The purpose of this study was to conduct a meta-analysis to determine if irrigation of breast implant pockets with antibiotics reduces the rate of capsular contracture (CC). Capsular contracture is the most common complication after primary augmentation mammoplasty, yet its etiology remains cryptogenic. METHODS: PubMed was searched for publications from January 1 of 2000 through October of 2015. Studies with the following criteria were included: primary breast augmentation with implants, use of antimicrobial irrigation (AMI), and documentation of CC. The primary outcome studied was incidence of CC. The quality of included studies was assessed independently. Studies were meta-analyzed to obtain a pooled odds ratio (OR) describing the effect of AMI on CC. RESULTS: The meta-analysis included 8 studies and 10,923 patients. A total of 5348 patients received AMI, and 5575 patients did not. Our analysis revealed that the combined AMI, the antibiotic irrigation subgroup, and the iodine subgroup were associated with an increased propensity for CC [OR, 2.60; 95% confidence interval (CI), 2.3-2.94, I = 97%, P < 0.00001; OR, 1.42; 95% CI, 1.14-1.78, I = 89%, P < 0.00001; OR, 0.54; 95% CI, 0.24-1.22, P = 0.05; I = 73], respectively. CONCLUSIONS: Antimicrobial irrigation of implant pockets fails to reduce the propensity for CC. The authors recommend that further prospective multicenter trials be conducted to further elucidate the role of antibiotic irrigation in CC.

A Novel Approach for the Treatment of Spider Veins.

BACKGROUND: Spider veins on the lower limbs are very common and have been reported to be present in 41% of women over 50. Sclerotherapy as a traditional treatment for spider veins has a low cost, though it may have adverse sequelae. Lasers have shown fewer but still substantial complications as well. Its lower efficacy relative to sclerotherapy has limited laser application for the treatment of spider veins. OBJECTIVES: To present a new alternative in management of spider veins which involves a low voltage current delivered via an insulated micro needle with beveled tip. METHODS: Thirty female patients were treated with the "Given Needle." The technique utilizes a micro needle with an insulated shaft with an exposed beveled tip, which is inserted into a hand piece connected to a mono-polar electrical generator. The needle is introduced through the skin into or on the spider vein. The current is then applied with obliteration of the vein. RESULTS: Twenty patients (66%) had more than a 70% resolution. The most common complication was skin erythema, which developed in 15 patients, followed by bruising in 13 patients. Both of these complications resolved in 2-3 weeks. CONCLUSIONS: A novel approach for the treatment of spider veins has been described. The development of an insulated micro needle with an exposed beveled tip utilizing low current has minimized adjacent tissue damage and improved efficacy. The low cost, low level of complications, and comparable results offer a valuable alternative to sclerotherapy and laser treatment.

Screw fixation of dermal regeneration template for scalp reconstruction.

Despite many advances in reconstructive techniques, the full-thickness scalp defect remains a difficult problem for the reconstructive surgeon. Patient and disease-specific factors occasionally make reconstruction with a dermal regeneration template (DRT) an attractive option when other methods are less advised. Although the applicability of dermal regeneration templates has been well elucidated, the method of DRT immobilization has not been standardized. Given the difficulty of adherence and subsequent infiltration of host cells into the DRT from the underlying bone due to seroma, hematoma, or shearing forces, we propose a screw and bolster system for DRT immobilization. We present a series of 13 patients with full-thickness scalp loss who underwent reconstruction with DRT and a subsequent split-thickness skin graft. All 13 patients were treated with the screw-bolster method of DRT fixation before a vacuum-assisted closure dressing. The average surface area of the defect was 96 cm. The mean time interval between the application of DRT and skin graft was 28 days. At a mean of 9-month follow-up, all patients achieved a well-vascularized neodermis, and progressed to complete, stable wound healing following application of a split-thickness skin graft. We propose that a screw-bolster system of fixation is a safe and effective method of immobilizing DRT in full-thickness scalp defects.

Breast cancer cell-derived fibroblast growth factor 2 and vascular endothelial growth factor are chemoattractants for bone marrow stromal stem cells.

OBJECTIVE: Recent efforts by the scientific community to characterize the complex interplay between different cell types involved in the development of tumors have led us to investigate the roles of vascular endothelial growth factor (VEGF) and fibroblast growth factor 2 (FGF2) in the development of breast cancer. METHODS: Using modified Boyden chamber assays, we measured the in vitro migration effect on murine mesenchymal stem cells (MSCs). Additionally, we assayed for the presence of receptors for these growth factors on MSCs, and for the presence of VEGF and FGF2 in breast cancer-conditioned media. We measured the change in migration of MSCs toward breast cancer when we depleted these growth factors from breast cancer-conditioned media. Further, we conducted a series of standard curve migration assays for basal media supplemented with physiologic concentrations of VEGF and FGF2. RESULTS: Analysis of gene expression and protein analysis demonstrated the expression of FGF2 and VEGF by the breast cancer cells, and the presence of VEGF (FLK1) and FGF2 receptors on the MSCs. We also demonstrated a reduction in migration when we antibody-depleted VEGF and FGF2 from breast cancer-conditioned media. Additionally, we found the physiologic concentrations of VEGF and FGF2 at 12 and 15 ng/mL, respectively. CONCLUSIONS: We demonstrate that VEGF and FGF2 induce migration of MSCs are secreted by breast cancer cells, their receptors are present on MSCs, and depletion of these growth factors reduces migration, and are therefore 2 relevant growth factors for MSC migration toward breast cancer cells.

Lipids isolated from bone induce the migration of human breast cancer cells.

Bone is the most common site to which breast cancer cells metastasize. We found that osteoblast-like MG63 cells and human bone tissue contain the bile acid salt sodium deoxycholate (DC). MG63 cells take up and accumulate DC from the medium, suggesting that the bone-derived DC originates from serum. DC released from MG63 cells or bone tissue promotes cell survival and induces the migration of metastatic human breast cancer MDA-MB-231 cells. The bile acid receptor farnesoid X receptor (FXR) antagonist Z-guggulsterone prevents the migration of these cells and induces apoptosis. DC increases the gene expression of FXR and induces its translocation to the nucleus of MDA-MB-231 cells. Nuclear translocation of FXR is concurrent with the increase of urokinase-type plasminogen activator (uPA) and the formation of F-actin, two factors critical for the migration of breast cancer cells. Our results suggest a novel mechanism by which DC-induced increase of uPA and binding to the uPA receptor of the same breast cancer cell self-propel its migration and metastasis to the bone.

High septal osteotomy in rhinoplasty for the deviated nose.

When attempting to straighten a patient's healed, deviated bony nasal dorsum, deviation of the central structure (high dorsal septum and medial nasal bones) must be addressed following the completion of medial and lateral osteotomies. When hump resection is not performed, blunt fracture (digitally or with forceps) of the deviated central structure is not a reliable method of mobilization, often leading to postoperative nasal drift. An intranasal osteotomy technique to mobilize the central structure of the nose is described, called "high septal osteotomy." Review of 25 cases suggests high septal osteotomy, supplemented as needed by resection of overlapping septal elements, can be performed safely and efficaciously, permitting stable midline reduction of the nasal pyramid. The technique is not advocated when hump resection is performed, as it is unnecessary and could destabilize the dorsum. Even aggressive maneuvers to mobilize the bony dorsum may fail if not performed properly with meticulous attention to completion of all osteotomies.