Nylon Suture Loop for Tagging Lymphatic Channels during Lymphaticovenular Anastomosis.

Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely. Method We propose a novel technique, which is used in LVA for tagging of lymphatic vessels, with the use of a nylon 6-0 suture and micro-ligaclip. Results We have successfully performed 78 LVAs in 26 cases with this method. The average lymphatic vessel size was 0.3 mm (0.15-0.8 mm). Conclusion This novel technique to implement the use of a nylon suture with a micro-ligaclip to use as a vessel loop for lymphatics has not been previously described in the literature. It is a useful technique that we find beneficial to lymphatic identification through tagging of the lymphatic channels, contributing to greater success in each anastomosis.

DIEP Donor Site Satisfaction between Patients with and without History of Pregnancy.

BACKGROUND: With the success of free autologous breast reconstruction, the abdominal donor site is now an important consideration, especially in patients of childbearing age. In our institution, there are increasing patients who have successfully undergone the deep inferior epigastric artery perforator (DIEP) flap despite previous pregnancy. This study aims to answer questions on the effect of the donor site on pregnancy and vice versa. METHODS: A retrospective cohort study was conducted to identify breast cancer patients who received a free DIEP flap for breast reconstruction from January 2018 to August 2020. Patients were allocated to two groups according to whether they had prior pregnancies with successful deliveries. Demographics, flap-related parameters, surgical outcomes on breast and abdomen, and patient-reported outcome (Breast-Q questionnaire) were analyzed. Patients were excluded if follow-up time was less than 1 year, or if there was incomplete medical records or Breast-Q replies. RESULTS: Ninety-nine of 116 patients had had successful pregnancies with delivery, 17 of them remained nulliparous. No statistically significant differences existed between groups regarding demographic data, flap-related parameters, surgical outcomes on breast and abdomen. Nulliparous patients exhibited significantly lower score in physical well-being in the abdomen domain compared with delivery-experienced patients (62.1 vs. 73.4, p = 0.025). Significantly, nulliparous patients felt more tightness and pulling of the abdominal wall than the delivery-experienced patients (2.9 vs. 3.7; p = 0.05 and 3.5 vs. 4.0; p = 0.04). CONCLUSION: Free DIEP flap can be transferred safely in nulliparous patients despite a slight increase in abdominal tightness and abdominal pulling. Precise flap design and surgical approaches may help to minimize the abdominal discomfort especially on young, normal body mass index, and nonchildbearing patients.

Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study.

OBJECTIVE: Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies. METHODS: There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy. RESULTS: The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups. CONCLUSION: With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.

Ultrafast excited state dynamics of isocytosine unveiled by femtosecond broadband time-resolved spectroscopy combined with density functional theoretical study.

Isocytosine, having important applications in antivirus and drug development, is among the building blocks of Hachimoji nucleic acids. In this report, we present an investigation of the excited state dynamics of isocytosine in both protic and aprotic solvents, which was conducted by a combination of methods including steady-state spectroscopy, femtosecond broadband time-resolved fluorescence, and transient absorption. These methods were coupled with density functional and time-dependent density functional theory calculations. The results of our study provide the first direct evidence for a highly efficient nonradiative mechanism achieved through internal conversion from the ππ* state of the isocytosine keto-N(3)H form occurring within subpicoseconds and picoseconds following photo-excitation. Our study also unveils a crucial role of solvent, particularly solute-solvent hydrogen bonding, in determining the tautomeric composition and regulating the pathways and dynamics of the deactivation processes. The deactivation processes of isocytosine in the solvents examined are found to be distinct from those of cytosine and the case known for isocytosine in the gas phase mainly due to different tautomeric forms involved. Overall, our findings demonstrate the high photo-stability of isocytosine in the solution and showcase the remarkable effect of covalent modification in altering the spectral character and excited state dynamics of nucleobases.

High-Fidelity Perforator Visualization for Cadaver Dissection in Surgical Training.

In the first half of the third century B.C., Herophilus and Erasistratus performed the first systematic dissection of the human body. For subsequent centuries, these cadaveric dissections were key to the advancement of anatomical knowledge and surgical techniques. To this day, despite various instructional methods, cadaver dissection remained the best way for surgical training. To improve the quality of education and research through cadaveric dissection, our institution has developed a unique method of perforator-preserving cadaver injection, allowing us to achieve high-fidelity perforator visualization for dissection studies, at low cost and high efficacy. Ten full body cadavers were sectioned through the base of neck, bilateral shoulder, and hip joints. The key was to dissect multiple perfusing arteries and draining veins for each section, to increase "capture" of vascular territories. The vessels were carefully flushed, insufflated, and then filled with latex dye. Our injection dye comprised of liquid latex, formalin, and acrylic paint in the ratio of 1:2:1. Different endpoints were used to assess adequacy of injection, such as reconstitution of eyeball volume, skin turgor, visible dye in subcutaneous veins, and seepage of dye through stab incisions in digital pulps. Dissections demonstrated the effectiveness of the dye, outlining even the small osseous perforators of the medial femoral condyle flap and subconjunctival plexuses. Our technique emphasized atraumatic preparation, recreation of luminal space through insufflation, and finally careful injection of latex dye with adequate curing. This has allowed high-fidelity perforator visualization for dissection studies.

Dynamic Reconstruction of Anal Sphincter with Camera Shutter Style Double-Opposing Gracilis Flaps.

Fournier's gangrene is a life-threatening infection which requires prompt recognition, early surgical debridement of unhealthy tissue, and initiation of broad-spectrum antibiotics. Relook debridement are usually performed until all the devitalized tissue has been removed. Involvement of the anal sphincter may result in significant morbidity such as permanent incontinence. Dynamic reconstruction of the anal sphincter has always been one of the holy grails in the field of pelvic reconstruction. We demonstrate a new method of camera shutter style double-opposing gracilis muscle flaps that allows dynamic sphincteric function without the need for electrostimulation. The bilateral gracilis muscles are inset in a fashion that allows orthograde contraction of the muscle to narrow and collapse the neoanal opening. With biofeedback training, the patient is able to regain dynamic continence and return to function without a stoma. There was also no need for neurotization or microsurgery techniques to restore sphincteric function to the anus. The patient was able to reverse his stoma 14 months after the initial insult and reconstruction with biofeedback training without the use of electrostimulation.

A case of cutaneous psoriasis vulgaris achieving complete remission post major breast reconstructive surgery.

Psoriasis is a debilitating chronic inflammatory systemic condition largely affecting the skin. Major surgery is relatively contraindicated due to the propensity for triggering psoriatic flares and koebnerization of the surgical scars. We detail an interesting case of complete psoriasis remission following a right nipple-sparing mastectomy with sentinel lymph node biopsy with vascular augmented pedicled transverse rectus abdominal myocutaneous (TRAM) flap in a patient with systemic psoriasis vulgaris and arthropathy. Intra-operatively, majority of the psoriatic plaques were excised or de-epithelized and used as part of the ipsilateral TRAM flap. Post-operatively, koebnerization did not occur and her psoriasis was cured completely even after cancer chemotherapy. One of several hypotheses include excision with de-epithelization of most of the psoriatic plaques reduces disease and inflammatory burden leading to complete remission. Perhaps, surgery could one day play a supporting role to existing treatment options to achieve psoriasis remission.

Extramammary Paget's disease: Our 15-year experience in a Southeast Asian population.

The treatment of choice for Extramammary Paget's disease (EMPD) is wide excision. However, owing to the tendency of microscopic spread and multi-centricity of the disease, resection margins are hard to determine. Despite the use of adjunctive methods such as mapping biopsy and Moh's micrographic surgery, recurrence rates remain high. We aim to establish treatment guidelines by determining the variables associated with recurrence and the optimal resection margin size. We reviewed 52 patients who underwent wide excision in our institution between 2002 and 2017. A retrospective review of patient demographics, disease characteristics, and resection margins was performed. Most patients were Chinese (n = 39, 75%) male (n = 38, 73.1%). The mean tumor size was 6.73 cm (SD=4.10; range, 1.50-21.0 cm). The mean resection margin was 2.5 cm (SD=1.21; range, 0.20-5.50 cm). Eleven patients (21.2%) had disease recurrence. Nodal involvement significantly correlated with disease recurrence or mortality related to disease (HR=4.645; 95% CI=1.539,14.018; p = 0.0064). Subgroup analysis showed a significant correlation between resection margin size and recurrence rates (p = 0.047). We observed that a smaller resection margin (<2 cm) is acceptable for smaller tumor sizes (<6 cm) to achieve the lowest possible recurrence rates (20%), whereas a larger resection margin (>2 cm) is required for larger tumor sizes (>6 cm) (p = 0.012). Our results suggest that a resection margin recommendation can be made in correlation to the tumor size. This serves as a guideline for surgeons to predict the defect size and provide options for reconstructive surgery while achieving low recurrence rates.

Excited-State Charge Transfer, Proton Transfer, and Exciplex Formation Revealed by Ultrafast Time-Resolved Spectroscopy in Human Telomeric Ribonucleic Acid Quadruplex.

Guanine quadruplexes (GQs), important for genome stability and biotechnology application, can form from both DNA and RNA. However, unlike the study of DNA GQs, little research has been conducted on excited states of GQs from RNA, which due to the ribose 2'-hydroxy group have structures distinct from their DNA counterparts. Combining ultrafast broadband time-resolved fluorescence and transient absorption measurements, we report the first direct probe of excitation dynamics for a bimolecular GQ from human telomeric repeat-containing RNA taking the typical highly compacted parallel folding with a propeller-like loop structure. The result revealed a multichannel decay containing an unusual high-energy excimer featuring charge transfer deactivated by rapid proton transfer in the tetrad core region. It also identified an unprecedented exciplex displaying massively red-shifted fluorescence produced from charge transfer in the loop region. The findings underscore the role of structural conformation and base content in determining the energy, electronic attribution, and decay dynamics of GQ excited states.

Reconstruction of a massive chest wall defect using a free anterolateral-lower medial thigh flaps: a case report.

Critical defects of the chest wall require robust soft tissue coverage to protect the thoracic viscera. We define massive chest wall defects as larger than two-thirds of the chest wall. For such defects, classic flaps like the omentum, latissimus dorsi and anterolateral thigh flaps are usually insufficient. In our patient, a bilateral total mastectomy for locally advanced breast cancer resulted in a massive chest wall defect (40 by 30 cm). Soft tissue coverage was achieved with a combined anterolateral-lower medial thigh flaps. Revascularization of the anterolateral thigh and lower medial thigh components was via the internal mammary and thoracoacromial vessels, respectively. Post-operative recovery was uneventful and the patient received adjuvant chemoradiotherapy in a timely manner. The total follow up was 24-months. We illustrate the novel use of the lower medial thigh territory in extending the size of the anterolateral thigh flap to reconstruct massive chest wall defects.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review.

PURPOSE: Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored. METHODS: We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed. RESULTS: Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed. CONCLUSION: ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Posterior cervical necrotising fasciitis: a multidisciplinary endeavour in surgery.

A 62-year-old male was diagnosed to the Emergency Department with 5-cm posterior neck carbuncle, and was subsequently discovered to have severe necrotising fasciitis intraoperatively during saucerization of the carbuncle. Subsequently, the patient was admitted to the intensive care unit and underwent combined debridement by the General Surgery, Neurosurgery and Plastic Surgery team. The large defect necessitated a trapezius flap reconstruction for coverage. Three months post-surgery, the patient had recovered well with the full range of movement of his neck.

Concussion and Psychological Effects: A Review of Recent Literature.

ABSTRACT: The aim of this article is to provide an up-to-date review of psychological changes in association with postconcussive athletes. In particular, this article focused on the symptomatology, risk factors, and treatment of psychiatric diagnoses in patients who suffered a sports-related concussion (SRC). After an extensive review of prior and current literature, there is significant evidence that demonstrates an association of changes in mood and behavior, including new or worsening symptoms of anxiety, depression, and difficulty with attention and concentration in those who are recovering from a concussion. The goal of care in these patients is to identify and treat these psychological symptoms early to have more favorable long-term outcomes. Primary treatment should focus on psychotherapy; however, other considerations may be warranted in certain cases, such as selective serotonin reuptake inhibitors for depression and tricyclic antidepressants and gabapentin for short-term cognitive symptom improvement.

Fixed prosthetic rehabilitation of a patient with Papillon-Lefevre syndrome supported by a Quad Zygoma Approach: A clinical report.

Papillon-Lefevere syndrome (PLS) is a rare disorder with severe oral manifestations resulting in premature tooth loss at an early stage of life. As a result, extensive bone resorption pattern in the maxilla negates conventional implant treatment in the majority of cases. This clinical report describes a prosthetic rehabilitation revision of a 26-year-old female diagnosed with PLS using an implant supported fixed complete denture with a quad zygoma approach. A 1 year follow-up is also presented.

Single stage chest wall soft tissue reconstruction with ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition.

Extravasation injury is a well-known complication of central venous catheter placement, with potential for extensive soft tissue necrosis. Here, we describe the case of a patient who developed a large right chest well soft tissue defect, due to a chest wall abscess from calcium gluconate infusion via a right internal jugular central venous catheter. After multiple debridements, the chest wall defect was reconstructed with a single stage ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition to match the contralateral nipple. There was no further infection, no nipple necrosis, and patient regained full range of motion of the ipsilateral shoulder.

Lower limb re-vascularization based on the angiosome concept with immediate-early local flap reconstruction: a case report.

Lower extremity wounds are a healthcare issue that can result in debilitating consequences. Peripheral arterial occlusive disease (PAOD) being a major contributing factor to the disease, advance revascularization procedures (Angioplasty) based on the angiosome concept has been established in the literature to improve blood supply and promote better healing outcomes. We present a case of a 59-year-old lady with background of hypertension, diabetes and PAOD, was diagnosed with a non-healing foot wound with exposed metal implant. She had targeted angioplasty done based on angiosome concept followed by early local flap reconstruction for coverage, which healed well without complications. Although free tissue transfer has now been the mainstay for lower limb reconstruction with the advancement in microsurgery. Local flaps remain in the armamentarium of lower extremity reconstruction with small to medium sized wound defects. This case demonstrates the advantage of proceeding with immediate-early local flap reconstruction following successful targeted re-vascularization.

Guidelines for Medical Immobilization/Protective Stabilization for Your Practice.

Many patients with special healthcare needs present to medical, dental, and other health visits with behavioral, emotional, postural, and psychological issues. According to the American Academy of Developmental Medicine and Dentistry (AADMD) guidelines from 2017: "Clinical dental treatment is the most exacting and demanding medical procedure that persons with special needs undergo on a regular basis throughout their lifetime." Moreover, dental treatment is basically surgical in nature, usually requiring controlled placement of sharpened instruments in intimate proximity to the face, airway, and highly vascularized and innervated oral tissues. When medically necessary healthcare must be provided and the patient's inability to accept or cooperate will compromise the quality of care the clinician will be able to deliver, interventions may be indicated and implemented.

Virtual Interview Day: An AEGD's approach and assessment of interviewing during a pandemic.

PURPOSE: A novel approach to interviewing for Advanced Education in General Dentistry residency positions became necessary during the COVID-19 pandemic. An efficient, virtual interview schedule, including video faculty introductions and clinic tour, was devised and executed to replace in-person interviews. The purpose of this study was to describe and assess this new way of managing virtual interviews. METHODS: Forty virtual interviews were conducted via a web-based videoconferencing platform. Interviewers and applicants received surveys to be anonymously completed after interviews. The applicant survey gauged how helpful each component of the interview process was in their program ranking decision. The interviewer survey assessed time and knowledge needed for interviewing, clarity of instructions, and if they felt valued. RESULTS: The response rate was 79% for applicants and 75% for interviewers. There was a high level of satisfaction from both applicants and interviewers. All interviewers reported that the team worked well together, instructions were clear, there was enough collective knowledge to answer questions, and they felt valued. There was a majority of positive responses for clarity of instructions and time with applicants. All applicants responded positively to correspondence with the Admissions Office, interview day instructions, informational PowerPoint, and sessions with the chief resident and program director. Regarding videos of faculty and clinic tour, there was a majority of positive responses. There were varying responses regarding the interview team being fair and nonthreatening. Lessons learned include reviewing on-camera behavior with interviewers, detailing the interview format in applicants' correspondence, requesting applicants photos in advance, allowing interviewers more time to study applicant material, and hosting a virtual happy hour for applicants and residents before the interview day. CONCLUSION: Overall, the Virtual Interview Day successfully achieved the goals of applicant and program rank selection. Virtual interviews can be considered an alternative to in-person interviews.