Systematic Review of Patient-Reported Outcomes and Complications of Pedicled Latissimus Flap Breast Reconstruction.

The latissimus dorsi (LD) flap is a reliable option for breast reconstruction. This is particularly true in patients with contraindications to abdominally based autologous breast reconstruction. A systematic review of patient satisfaction and health related quality of life following LD breast reconstruction using the BREAST-Q survey was conducted. The scope of the review was to determine the degree of patient satisfaction following the procedure and to examine how patient satisfaction from the pedicled LD flap compares to other breast reconstructive procedures. A literature search on BREAST-Q in LD flap reconstruction was performed. Only articles written in English and in published peer-reviewed journals were included. Studies with less than 20 patients in their sample and those with a follow-up period of less than 1 year were excluded. Five articles representing 331 patients were reviewed, including one case-control study and four retrospective cohort studies. Level of evidence was either III (4) or IV (1). The average age was 53 with average body mass index of 25. Most reconstructions were delayed (67%) and unilateral (88%), and most patients required radiation (79%). The average length of follow-up was 36 months, and the response rate was 75%. Overall, patients who underwent LD flap reconstruction reported favorable outcomes in satisfaction domains and quality of life domains with few complications. A meta-analysis also demonstrated higher satisfaction in LD flap without implants compared with LD flap with implants. Patient-reported outcomes following LD breast reconstruction compare favorably with other techniques of breast reconstruction.

Common Iliac Artery to Below-Knee Popliteal Artery Bypass via Obturator Foramen in a Third-Time Reoperative Groin for Limb Salvage in Chronic Limb-Threatening Ischemia.

This case report presents the management of a 69-year-old man with an extensive history of peripheral vascular disease including 2 previous failed right femoral to distal bypasses and a left above-the-knee amputation who presented with right lower extremity rest pain and non-healing shin ulcers. A redo bypass was performed for limb salvage via the obturator foramen to avoid his extensively scarred femoral region. The postoperative course was uneventful and the bypass remained patent in the early period. This case demonstrates the usefulness of the obturator bypass to provide revascularization and avoid amputation in a patient with chronic limb-threatening ischemia and multiple failed bypasses.

Treatment of VPI with Customized Pharyngeal Flaps: One Size Does Not Fit All.

Failure of complete closure of the velopharyngeal sphincter results in velopharyngeal insufficiency (VPI), which may severely interfere with speech. The pharyngeal flap remains a common procedure for correcting VPI. We aimed to study whether customization of pharyngeal flaps using a dynamic preprocedural assessment can result in successful outcomes in the surgical treatment of VPI, despite variations in surgical technique. Methods: This is a retrospective review of patients between the ages 4 and 18 years old with VPI who underwent surgical correction by one of four surgeons at our institution. All four surgeons used a superiorly based pharyngeal flap (SBPF) with slight variations in operative technique. All patients also received an evaluation by the speech and language pathologist that included nasometry, multiplanar videofluoroscopy, and flexible videonasopharyngoscopy. Individualized preoperative planning was performed based on the findings. Results: In total, 158 patients (92%) demonstrated overall successful correction of VPI, defined by a normal post-operative mean nasalance. Thirteen patients (8%) presented with resonance improvement but persistent abnormal mean nasalance. The most common causes of failed VPI correction were inferior migration and/or shrinking of the pharyngeal flap. There was a nonsignificant association between surgical technique and unsuccessful corrections. Conclusions: The optimal surgical approach for performing pharyngeal flaps to correct VPI is individualized, customizing the procedure based on preoperative imaging. This study demonstrates that despite variations in surgical techniques for performing SBPF, high rates of success can be achieved when adequate surgical planning is based on imaging findings.

Acute appendicitis severity during the early COVID-19 pandemic period.

BACKGROUND: The early COVID-19 pandemic period significantly strained the US healthcare system. During this period, consultations and admissions for acute medical conditions decreased, which was associated with an increase in disease-specific morbidity and mortality. Therefore, we sought to determine what, if any, effect the early COVID-19 pandemic period had on the presentation, management, and histopathologic severity of acute appendicitis. METHODS: We performed a retrospective, observational study to compare the frequencies with which patients presented with acute appendicitis, the proportion of whom were managed surgically, and the distribution of histopathologic disease severity among all resected appendix specimens during the early COVID-19 pandemic period (March 6-June 30, 2020) to equivalent time periods for the 3 preceding/pre-pandemic years (2017-2019). RESULTS: Compared with equivalent pre-pandemic time periods, during the COVID-19 pandemic period there was no significant difference in the number of patients who presented for acute appendicitis, there was a decreased rate of surgical management (81% vs 94%; p=0.014), and there was an overall increase in the incidence of perforated appendicitis (31% vs 16%; p=0.004), including by histopathologic diagnosis (25% vs 11%; p=0.01). DISCUSSION: Despite potential patient hesitancy to present for care, the early COVID-19 pandemic period was associated with no significant change in the number of patients presenting with acute appendicitis; however, there was a significant increase in the incidence of perforated appendicitis. This study highlights the need to encourage patients to avoid late presentation for acute surgical conditions and for the robust planning for the medical management of otherwise surgical abnormalities during episodes of restricted or limited resources. LEVEL OF EVIDENCE: Level III.

Drosophila Condensin II subunit Chromosome-associated protein D3 regulates cell fate determination through non-cell-autonomous signaling.

The pattern of the Drosophila melanogaster adult wing is heavily influenced by the expression of proteins that dictate cell fate decisions between intervein and vein during development. dSRF (Blistered) expression in specific regions of the larval wing disc promotes intervein cell fate, whereas EGFR activity promotes vein cell fate. Here, we report that the chromatin-organizing protein CAP-D3 acts to dampen dSRF levels at the anterior/posterior boundary in the larval wing disc, promoting differentiation of cells into the anterior crossvein. CAP-D3 represses KNOT expression in cells immediately adjacent to the anterior/posterior boundary, thus blocking KNOT-mediated repression of EGFR activity and preventing cell death. Maintenance of EGFR activity in these cells depresses dSRF levels in the neighboring anterior crossvein progenitor cells, allowing them to differentiate into vein cells. These findings uncover a novel transcriptional regulatory network influencing Drosophila wing vein development, and are the first to identify a Condensin II subunit as an important regulator of EGFR activity and cell fate determination in vivo.