Clinicomics-guided distant metastasis prediction in breast cancer via artificial intelligence.

BACKGROUND: Breast cancer has become the most common malignant tumour worldwide. Distant metastasis is one of the leading causes of breast cancer-related death. To verify the performance of clinicomics-guided distant metastasis risk prediction for breast cancer via artificial intelligence and to investigate the accuracy of the created prediction models for metachronous distant metastasis, bone metastasis and visceral metastasis. METHODS: We retrospectively enrolled 6703 breast cancer patients from 2011 to 2016 in our hospital. The figures of magnetic resonance imaging scanning and ultrasound were collected, and the figures features of distant metastasis in breast cancer were detected. Clinicomics-guided nomogram was proven to be with significant better ability on distant metastasis prediction than the nomogram constructed by only clinical or radiographic data. RESULTS: Three clinicomics-guided prediction nomograms on distant metastasis, bone metastasis and visceral metastasis were created and validated. These models can potentially guide metachronous distant metastasis screening and lead to the implementation of individualized prophylactic therapy for breast cancer patients. CONCLUSION: Our study is the first study to make cliniomics a reality. Such cliniomics strategy possesses the development potential in artificial intelligence medicine.

Aquaporins in Skin.

The skin is the largest organ of our body and plays a protective role against the external environment. The skin functions as a mechanical and water permeability barrier, assisting with thermoregulation and defending our body against a variety of stresses such as ultraviolet radiation, microbial infection, physical injuries, and chemical hazards. The structure of the skin consists of three main layers: the hypodermis, the dermis, and the epidermis. Aquaporins (AQPs) are a family of integral membrane proteins whose function is to regulate intracellular fluid hemostasis by facilitating the transportation of water, and in some cases small molecules, across the cell membranes. Up to six different AQPs (AQP1, 3, 5, 7, 9, and 10) are expressed in a variety of cell types in the skin. The AQP family plays an important role in these various locations, contributing to many key functions of the skin including hydration, wound healing, and immune responses. The involvement of different aquaporin family members in skin is discussed.

Single-Institution Algorithm for Prevention and Management of Complications in Direct-to-Implant Breast Reconstruction.

BACKGROUND: Complications including infection and wound dehiscence are major concerns for direct-to-implant breast reconstruction. However, the risk factors associated with severe complications and implant salvage remain unclear. METHODS: This was a retrospective study of all patients undergoing unilateral direct-to-implant breast reconstruction from 2014 through 2019. The risk factors associated with complications and prosthesis explantation were identified using multivariate logistic regression modeling and interaction analyses. RESULTS: Among 1027 patients enrolled, 90 experienced severe complications, 41 of whom underwent prosthesis explantation; 49 were successfully salvaged. Multivariate analysis demonstrated that patients with larger implant size ( p = 0.003), use of bovine mesh ( p < 0.001), adjuvant radiotherapy ( p = 0.047), low plasma albumin ( p = 0.013), and elevated blood glucose ( p = 0.006) were significantly more likely to have complications. Adjuvant radiation therapy (OR, 7.44; 95 percent CI, 1.49 to 37.18; p = 0.014) and obesity (OR, 4.17; 95 percent CI, 1.17 to 14.88; p = 0.028) were associated with significantly lower rates of implant salvage and surgical-site infection and wound dehiscence, whereas mastectomy skin flap necrosis was not associated with device explantation. There were no differences in complication and explantation rates between nipple-sparing and skin-sparing mastectomies. However, the combined impact of surgical-site infection and wound dehiscence added a greater than 14-fold higher risk of prosthesis explantation (95 percent CI, 9.97 to 19.53). CONCLUSIONS: Success in direct-to-implant breast reconstruction is multifactorial. Larger implant size, adjuvant radiation therapy, diabetes, and malnutrition demonstrate increased risk of complications in the direct-to-implant approach. Surgical-site infections and wound dehiscence should be treated aggressively, but the combination of both complications portends poor salvage rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Survival Estimation, Prognostic Factors Evaluation, and Prognostic Prediction Nomogram Construction of Breast Cancer Patients with Bone Metastasis in the Department of Bone and Soft Tissue Tumor: A Single Center Experience of 8 Years in Tianjin, China.

Purpose: Bone metastasis in breast cancer remains globally concerned. Accurate survival estimation would be beneficial for clinical decision-making, especially for the patients with potential indications of surgery. Based on a retrospective cohort from China, the study aimed to construct a prognostic prediction nomogram for breast cancer patients with bone metastasis. Methods: Breast cancer patients with bone metastasis diagnosed between 2009 and 2017 in our department were retrospectively selected. The total cohort was divided into construction and validation cohorts (ratio 7 : 3). A nomogram was constructed to predict the probability of survival, and the performance of model was validated. Results: A total of 343 patients were enrolled with 243 and 100 patients in construction and validation cohorts, respectively. The median overall survival for the total cohort was 63.2 (95% CI: 52.4-74.0) months. Elevated ALP (HR = 1.71, 95% CI: 1.16-2.51; P=0.006), no surgery for breast cancer (HR = 2.19, 95% CI: 1.30-3.70; P=0.003), synchronous bone metastasis (HR = 1.98, 95% CI: 1.22-3.22; P=0.006), and liver metastasis (HR = 1.68, 95% CI: 1.20-2.37; P=0.003) were independent prognostic factors for worse survival. The independent predictors and other five factors (including age at diagnosis, ER status, PR status, Her-2 status, and the performance of bisphosphonate) were incorporated to construct the nomogram. The C-index was 0.714 (95% CI: 0.636-0.792) and 0.705 (95% CI: 0.705) in the construction cohort and validation cohort, respectively. All the calibration curves were close to the 45-degree line, which indicated satisfactory calibration. Conclusion: A retrospective study aiming at prognostic estimation of breast cancer patients with bone metastasis was designed. Four independent prognostic factors were identified and a prognostic nomogram was constructed with satisfactory discrimination and calibration. The model could be used in survival estimation and individualized treatment planning.

Comparison of outcomes between immediate implantbased and autologous reconstruction: 15-year, single-center experience in a propensity score-matched Chinese cohort.

OBJECTIVE: The number of immediate breast reconstruction (IBR) procedures has been increasing in China. This study aimed to investigate the oncological safety of IBR, and to compare the survival and surgical outcomes between implant-based and autologous reconstruction. METHODS: Data from patients diagnosed with invasive breast cancer who underwent immediate total breast reconstruction between 2001 and 2016 were retrospectively reviewed. Long-term breast cancer-specific survival (BCSS), disease-free survival (DFS), and locoregional recurrence-free survival (LRFS) were evaluated. Patient satisfaction with the breast was compared between the implant-based and autologous groups. BCSS, DFS, and LRFS were compared between groups after propensity score matching (PSM). RESULTS: A total of 784 IBR procedures were identified, of which 584 were performed on patients with invasive breast cancer (implant-based, n = 288; autologous, n = 296). With a median follow-up of 71.3 months, the 10-year estimates of BCSS, DFS, and LRFS were 88.9% [95% confidence interval (CI) (85.1%-93.0%)], 79.6% [95% CI (74.7%-84.8%)], and 94.0% [95% CI (90.3%-97.8%)], respectively. A total of 124 patients completed the Breast-Q questionnaire, and no statistically significant differences were noted between groups (P = 0.823). After PSM with 27 variables, no statistically significant differences in BCSS, DFS, and LRFS were found between the implant-based (n = 177) and autologous (n = 177) groups. Further stratification according to staging, histological grade, lymph node status, and lymph-venous invasion status revealed no significant survival differences between groups. CONCLUSIONS: Both immediate implant-based and autologous reconstruction were reasonable choices with similar long-term oncological outcomes and patient-reported satisfaction among patients with invasive breast cancer in China.

RIPK1 is a negative mediator in Aquaporin 1-driven triple-negative breast carcinoma progression and metastasis.

The triple-negative breast carcinoma (TNBC) is the most aggressive subtype of breast cancer. In TNBC, Aquaporin 1 (AQP1), a water-transporting transmembrane protein, is aberrantly enriched in cytoplasm and causes tumor cell death evasion. However, the carcinogenetic bioactivities of cytoplasmic AQP1 cannot be attributed to the canonical "osmotic engine model". In the present study, the receptor-interacting protein kinase 1 (RIPK1), a cell death regulator, was identified to negatively mediate AQP1-driven TNBC progression and metastasis. AQP1 overabundance and RIPK1 depletion occurred in TNBC, which were correlated with aggressive oncological features and poor prognosis. AQP1 bound with RIPK1, resulting in the inhibition of RIPK1/RIPK3/MLKL-mediated necroptosis and RIPK1/caspase-8/caspase-3-mediated apoptosis. Genetic inhibition of RIPK1 significantly exacerbated the pro-tumor effect of AQP1, while ectopic expression of RIPK1 notably blunted AQP1 signaling. Mechanistically, AQP1 binds to the D324 site of RIPK1, and facilitates RIPK1 cleavage and inactivation by excessively activating the caspase-8/RIPK1 negative feedback loop. RIPK1D324K overexpression significantly prevented RIPK1 cleavage and weakened the aggressiveness of AQP1-enriched TNBC cells. Overall, our findings clarify the underlying mechanism of cytoplasmic AQP1-driven TNBC progression and metastasis, in which RIPK1 exerts an essential role as a negative mediator and exhibits the potential as a therapeutic target for TNBC.

Inhibition of α1-adrenoceptor reduces TGF-ß1-induced epithelial-to-mesenchymal transition and attenuates UUO-induced renal fibrosis in mice.

Renal fibrosis is a common pathological hallmark of chronic kidney disease (CKD). Renal sympathetic nerve activity is elevated in patients and experimental animals with CKD and contributes to renal interstitial fibrosis in obstructive nephropathy. However, the mechanisms underlying sympathetic overactivation in renal fibrosis remain unknown. Norepinephrine (NE), the main sympathetic neurotransmitter, was found to promote TGF-ß1-induced epithelial-mesenchymal transition (EMT) and fibrotic gene expression in the human renal proximal epithelial cell line HK-2. Using both genetic and pharmacological approaches, we identified that NE binds Gαq-coupled α1-adrenoceptor (α1-AR) to enhance EMT of HK-2 cells by activating p38/Smad3 signaling. Inhibition of p38 diminished the NE-exaggerated EMT process and increased the fibrotic gene expression in TGF-ß1-treated HK-2 cells. Moreover, the pharmacological blockade of α1-AR reduced the kidney injury and renal fibrosis in a unilateral ureteral obstruction mouse model by suppressing EMT in the kidneys. Thus, sympathetic overactivation facilitates EMT of renal epithelial cells and fibrosis via the α1-AR/p38/Smad3 signaling pathway, and α1-AR inhibition may be a promising approach toward treating renal fibrosis.

Distant metastasis prediction via a multi-feature fusion model in breast cancer.

This study aimed to develop a model that fused multiple features (multi-feature fusion model) for predicting metachronous distant metastasis (DM) in breast cancer (BC) based on clinicopathological characteristics and magnetic resonance imaging (MRI). A nomogram based on clinicopathological features (clinicopathological-feature model) and a nomogram based on the multi-feature fusion model were constructed based on BC patients with DM (n=67) and matched patients (n=134) without DM. DM was diagnosed on average (17.31±13.12) months after diagnosis. The clinicopathological-feature model included seven features: reproductive history, lymph node metastasis, estrogen receptor status, progesterone receptor status, CA153, CEA, and endocrine therapy. The multi-feature fusion model included the same features and an additional three MRI features (multiple masses, fat-saturated T2WI signal, and mass size). The multi-feature fusion model was relatively better at predicting DM. The sensitivity, specificity, diagnostic accuracy and AUC of the multi-feature fusion model were 0.746 (95% CI: 0.623-0.841), 0.806 (0.727-0.867), 0.786 (0.723-0.841), and 0.854 (0.798-0.911), respectively. Both internal and external validations suggested good generalizability of the multi-feature fusion model to the clinic. The incorporation of MRI factors significantly improved the specificity and sensitivity of the nomogram. The constructed multi-feature fusion nomogram may guide DM screening and the implementation of prophylactic treatment for BC.

Preventive and Therapeutic Effect of Ganoderma (Lingzhi) on Skin Diseases and Care.

Ganoderma lucidum (G. lucidum, Lingzhi), a kind of mushroom with various bioactivities, is recently revealed to improve skin quality and treat skin diseases. Traditionally, polysaccharides and ganoderic acids have been reported as the major functional metabolites of Ganoderma possessing antioxidant and anti-inflammatory functions. Based on our research and other studies, Ganoderma extracts, such as Ganoderma polysaccharides, have been used in promoting skin wound healing, mitigating postburn infection, and preventing skin flap ischemia-reperfusion injury. Ganoderma extracts have also been used in skin care, because of their roles in skin photoaging and skin whitening. Meanwhile, the anti-inflammatory effect of Ganoderma in atopic dermatitis and cutaneous sarcoidosis is also elaborated in this chapter. Finally, the potential use of Ganoderma in skin carcinoma is introduced. In brief, the dermoprotective effect of Ganoderma will be summarized in this chapter.

Association of sociodemographic and oncological features with decision on implant-based versus autologous immediate postmastectomy breast reconstruction in Chinese patients.

BACKGROUND AND OBJECTIVES: Immediate postmastectomy breast reconstruction (IPBR) has gained wide popularity in China. We sought to clarify the prevalence and predictors of implant-based vs autologous IPBR among Chinese patients. METHODS: A retrospective cohort study was performed using a prospectively maintained database. Women who underwent IPBR during 2001-2017 were included. The modality-specific trends were deciphered by curve fitting analysis. The association of sociodemographic and oncological features with the decision for implant-based vs autologous IPBR was investigated using multivariate logistic regression and structural equation modeling. RESULTS: Among 905 patients included in the study, 479 underwent implant-based IPBR and 426 underwent autologous procedures. The implant/autologous ratio has increased exponentially over time. Multivariate analysis demonstrated that unmarried patients with BMI ≤ 24 kg/m2 , earlier clinical tumor stage, and preoperative pathological diagnosis of noninvasive lesion are more likely to choose implant-based IPBR compared to autologous procedures. The indirect effects of age, mastectomy type, and neoadjuvant chemotherapy were further demonstrated by the structural equations. CONCLUSIONS: The sociodemographic and oncological features are directly or indirectly associated with the decision on type of IPBR. The findings may facilitate both patients and physicians to make a high-quality decision by holistic evaluation of the sociodemographic and oncological features.

Single-Surgeon Experience for Maximizing Outcomes in Implant-Based Breast Reconstruction in Chinese Patients.

INTRODUCTION: Breast reconstruction for Chinese patients is vastly different given cultural differences, patient preferences, access to resources, and insurance coverage in China. Given these unique factors, a different approach for optimizing outcomes should be considered. METHODS: Retrospective review of all patients undergoing implant-based breast reconstruction from January 2013 to May 2016 was performed. Esthetic evaluations were made both by the patients and 1 nonoperative surgeon at least 6 months postoperative, and patient satisfaction was assessed using the Breast-Q. RESULTS: Overall, 135 patients undergoing 141 implant-based breast reconstructions were reviewed. The majority of implants (n = 134) were placed in a subpectoral position, whereas 7 were placed prepectorally, and no acellular dermal matrix was used. Given the limitations in acellular dermal matrix usage, soft-tissue coverage was augmented with local regional flaps. Ninety-four reconstructions (66.7%) used latissimus dorsi, 39 (27.7%) used serratus anterior, and 7 (5.0%) used mastectomy skin flaps only for implant coverage. Four patients (2.8%) underwent revision surgery to the reconstructed breasts. Grade III and grade IV capsular contracture was observed in 10 (7.1%) and 2 (1.4%) reconstructions, respectively. Both the patient's and the surgeon's satisfaction were higher than 80% in breast symmetry. CONCLUSIONS: Our implant selection method fit the Chinese population characteristics and could be extended to different types of implant-based breast reconstruction. It produced good esthetic outcomes and was reproducible, predictable, and simple to master in the clinical setting.

Ganoderma lucidum Polysaccharide Peptide Attenuates Skin Flap Ischemia-Reperfusion Injury in a Thioredoxin-Dependent Manner.

BACKGROUND: Thioredoxin-1 plays an important role in protecting the skin flap from ischemia-reperfusion injury. Ganoderma lucidum polysaccharide peptide is the major component of G. lucidum, which possesses potent antioxidant and antiapoptotic activity. This study aims to determine whether G. lucidum polysaccharide peptide could attenuate skin flap ischemia-reperfusion injury and to investigate possible mechanisms involved. METHODS: G. lucidum polysaccharide peptide was administered to mice and epidermal cells before ischemia-reperfusion and hypoxia/reoxygenation, respectively. The thioredoxin-1 inhibitor PX-12 was introduced in the counterevidence group. The flap tissues and cells were tested by hematoxylin and eosin and immunohistochemistry staining, terminal deoxynucleotidyl transferase-mediated dUDP end-labeling assay, superoxide dismutase and malonic dialdehyde measurement, and Western blot. RESULTS: The survival rates of ischemia-reperfusion flaps and hypoxia/reoxygenation cells increased significantly following G. lucidum polysaccharide peptide treatment. Mitigated tissue damage, reduced apoptosis, and enhanced antioxidant activity were observed in ischemia-reperfusion flaps replenishing G. lucidum polysaccharide peptide. Western blot analysis revealed thioredoxin-1 depletion and a remarkable increase in ASK-1, phospho-p38, cleaved caspase-3, and cleaved PARP abundance in ischemia-reperfusion flaps and hypoxia/reoxygenation cells, whereas G. lucidum polysaccharide peptide dramatically up-regulated thioredoxin-1 and reduced the apoptosis-related protein expression. However, the rescue effect of G. lucidum polysaccharide peptide was notably blunted by supplementation with PX-12. CONCLUSIONS: The current investigation highlights the protective role of G. lucidum polysaccharide peptide in skin flap ischemia-reperfusion injury through a thioredoxin-1-dependent antioxidant and antiapoptotic pathway. This initial foray demonstrates the therapeutic value of G. lucidum polysaccharide peptide against ischemia-reperfusion and facilitates the understanding of its dermoprotective mechanism.

Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation.

INTRODUCTION: Prosthesis-assisted penile reconstruction has been performed extensively to restore a cosmetically acceptable phallus. However, a large number of patients will undergo revision surgery for various prosthesis-related complications. AIM: To develop a 1-stage prosthesis-free dynamic cavernosa reconstruction method using bilateral innervated gracilis muscles and to investigate the feasibility and reliability of the surgical design. METHODS: 10 fresh cadavers were dissected to assess the availability of bilateral gracilis muscles for functional cavernosa rebuilding. 11 mongrel female dogs were involved in the penile reconstruction surgery. The neophallus consisted of bilateral gracilis muscles as the neo-cavernosa, a right gracilis skin flap as the neourethra, and a lower abdominal flap with an anterior rectus sheath as the skin envelope and neo-tunica albuginea. The function and structure of the neo-phalli were assessed 7 months postoperatively. MAIN OUTCOME MEASURES: The neurovascular pedicle length of the gracilis muscles and the volume of the gracilis venter musculi were measured in the cadaveric investigation. The average dimensions of the canine neo-phalli at rest and during electrostimulated erection were obtained and the muscular fatigue-resistant curve was drawn. Histologic evaluations also were performed. RESULTS: The neurovascular pedicle length and volume of the gracilis muscles were sufficient to yield a nearly normal appearance of the neo-cavernosa in the cadaveric and animal studies. The muscular fatigue-resistant curve demonstrated adequate length, stiffness, and duration of erection of the neo-phalli to accomplish normal coitus. Histologic evaluations showed an intact neourethra and nearly normal muscle structure in the inner layer of the canine neo-cavernosa, except for significantly increased amount of collagen fibers and type I/III collagen ratio in the outer layer of the neo-cavernosa. The percentage of type II (fatigue-prone) muscle fibers did not change significantly. CONCLUSION: Our preclinical investigation proves that corpora cavernosa reconstruction using bilateral innervated gracilis muscles is technically feasible and functionally efficacious. Yin Z, Liu L, Xue B, et al. Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation. Sex Med 2018;6:162-170.

Expanded Cheek-Shaped Flap for Aesthetic Cheek Reconstruction in the Cervicoperiauricular Area.

BACKGROUND: The cervical area is well acknowledged as an ideal donor site for aesthetic reconstruction of the cheek, and tissue expansion may play an important role for maximally achieving such a purpose. However, the conventional design of the expanded cervical flap generally results in unsightly morbidity of the donor site. The aim of this study is to evaluate the results of using an improvised cervical expanded flap in aesthetic reconstruction of the cheek. METHODS: From July 2004 to October 2012, a total of 23 burn sequelae patients (30 cheeks) underwent cheek reconstruction with an expanded flap that originated from the cervicoperiauricular area. The procedures were initially carried out with the insertion of a round tissue expander in the cervicoperiauricular area, followed by serial inflation of the expander, and finally, transplantation of the expanded flap to the cheek in a rotation advancement fashion. The donor site closure was along the auricular sulcus. RESULTS: The average area of the harvested flaps was 9.7 × 8.1 cm. All the flaps completely survived, only one major complication occur-a dome exposure of the tissue expander after the expansion was completed. The flap was salvaged, and the transfer stage was done without intact. Minor complications after flap transfer include: widened scar at the donor site, a "dog-ear" needing additional minor surgery, distal part of the flap transient congestion. The patients achieved very satisfactory results functionally and aesthetically. CONCLUSIONS: Using the expanded cheek-shaped flap technique can provide a safe, thin, and color-matched flap in aesthetic reconstruction of the cheek with minimal donor site morbidity.

Thioredoxin Protects Skin Flaps from Ischemia-Reperfusion Injury: A Novel Prognostic and Therapeutic Target.

BACKGROUND: Ischemia-reperfusion injury is inevitable during free-tissue transfer, causing oxidative damage and extensive apoptosis. Thioredoxin is an endogenous protein with antioxidant and antiapoptotic activity in a variety of tissues. This study aims to investigate the protective effects of human thioredoxin-1 on ischemia-reperfusion flaps, and its clinical application value. METHODS: Sixteen clinical specimens of ischemia-reperfusion flaps were collected and assessed for apoptosis and thioredoxin-1 expression. Eighty mice were administered recombinant human thioredoxin-1 or saline intraperitoneally for 5 days before ischemia-reperfusion. Half of the mice were killed 24 hours after reperfusion. The flap tissues were harvested and detected for the changes of morphology, apoptosis, redox condition, and relative protein expression. The flap survival percentage of the remaining mice was consecutively observed within 7 days of reperfusion. RESULTS: Thioredoxin-1 abundance was negatively correlated with ischemia-reperfusion-induced apoptosis in human samples and animal models. The survival rate of the ischemia-reperfusion flaps in mice increased significantly following recombinant human thioredoxin-1 pretreatment. Mitigated tissue damage, reduced apoptosis, and more antioxidant activity were observed in recombinant human thioredoxin-1-pretreated flaps. Western blot analysis revealed thioredoxin-1 depletion and a significant increase in apoptosis signal-regulating kinase 1, p-p38, and cleaved caspase-3 abundance in the ischemia-reperfusion flaps, whereas supplementation of recombinant human thioredoxin-1 significantly reduced the apoptosis-related protein expression. CONCLUSIONS: Thioredoxin-1 exerts its flap-protective role through redox regulation of reactive oxygen species scavenging and antiapoptotic signaling. The authors' research provides evidence that thioredoxin-1 may serve as a potential prognostic and therapeutic target for skin flap ischemia-reperfusion injury.

Self-esteem, Self-efficacy, and Appearance Assessment of Young Female Patients Undergoing Facial Cosmetic Surgery: A Comparative Study of the Chinese Population.

IMPORTANCE: The psychological traits of cosmetic surgery patients (CSP) are important for selecting patients and postoperative patient satisfaction. A patient's self-esteem, self-efficacy, and self-assessment affect his or her motivation for cosmetic surgery, but the association among these traits remains unclear, especially in the Asian population. OBJECTIVE: To clarify the association of a patient's psychological traits, decision to undergo cosmetic surgery, and the effectiveness of facial cosmetic surgery on the psychological conditions of young, female Chinese patients. DESIGN, SETTING, AND PARTICIPANTS: Three different groups of young women (aged 18-30 years) from the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and 7 universities were enrolled from January 1, 2012, through December 31, 2014: CSPs (n = 161), general population controls (GPCs) (n = 355), and facial appearance raters (FARs) (n = 268). The last date of follow-up was January 20, 2015. Patient data from questionnaires were obtained preoperatively and 6 months postoperatively, and the data from the control groups were obtained immediately after enrollment. Front-view facial images of the study participants were taken and then shown to independent raters to assess the participants' facial appearances on a rating scale. MAIN OUTCOMES AND MEASURES: Evaluation of self-esteem and self-efficacy, subjective and objective assessment of facial appearance, and structural equation models. RESULTS: A total of 163 CSPs and 387 GPCs were recruited for the study, and complete and valid data were obtained from 161 CSPs and 355 GPCs. All responses from the 268 FARs met the criteria for subsequent analysis. Of the questionnaires issued to the CSPs 6 months postoperatively, 126 valid responses were returned (response rate, 78.3%). Self-esteem and self-efficacy decreased significantly in preoperative patients compared with controls (P < .001) (mean [SD] scores, 22.60 [1.80] for CSPs and 27.39 [2.11] for GPCs for self-esteem and 21.50 [2.40] for CSPs and 28.59 [4.23] for GPCs for self-efficacy) and were found to be at nearly normal levels 6 months postoperatively (mean [SD] scores, 25.88 [3.65] and 26.38 [2.45] for self-esteem and self-efficacy, respectively). The patients' objective assessments of facial appearance did not differ significantly from those of the control group participants (mean [SD] scores, 4.51 [0.77] and 4.55 [0.74] for CSPs and GPCs, respectively; P = .86); however, a significant decrease in patient self-assessment was noted (mean [SD scores], 6.45 [1.15] and 7.31 [1.42] for CSPs and GPCs, respectively; P = .01). Moreover, the structural equation models revealed a path from low self-esteem and self-efficacy after decreased self-assessment to decision for cosmetic surgery. CONCLUSIONS AND RELEVANCE: Self-esteem and self-efficacy mediate the negative effects of self-assessment on the decision of young women to undergo facial cosmetic surgery. The impairment of self-esteem and self-efficacy may indicate the need for preoperative psychological intervention. Facial cosmetic surgery can have positive effects on self-esteem and self-efficacy. LEVEL OF EVIDENCE: 2.

[Functional penile reconstruction with skin flaps combined with muscle: a preclinical study].

Objective: To devAop a new approach for functional penile reconstruction. Methods: Total penile reconstruction using innervated gracilis muscles and anterolateral thigh (ALT) flap with fascia lata was performed on four human cadavers. Canine models were constructed using gracilis muscles and lower abdominal flap with anterior rectus sheaih, instead of the ALT flap. Seven months later, the erectile function of the neophalli elicited by electrostimulation was evaluated. The length, diameter and stiffness were measured respectively and the results were analyzed statistically using paired-samples t test. Results: The penile reconstruction was success with good appearance in the cadaveric study. The hardness of the reconstructed penis in canine models was graded as 1.2 ± 0.4 at rest. With the nerve pedicles stimulated, it increased significantly and was graded as 3.4 ± 0.5 (P ＜ 0.05),while the length shortened and the diameter did not change significantly. A successful erection-mimic course was observed. Conclusions: It indicates that penile reconstruction with skin flaps combined with muscle is feasible, serving as a theoretical and technical support for further clinical application.

Upper and Lower Eyelid Full Thickness Reconstruction Using a Retrograde Postauricular Island Flap.

Upper and lower eyelid full-thickness reconstruction in a patient without available adjacent tissue because of burns or trauma is a surgical challenge. Our patient had severe thermal burns with complete unilateral defects in both the upper and lower eyelids. Although the skin grafts survived, contraction occurred quickly, subsequent ectropion of both the upper and lower eyelids, which could have lead to exposure keratitis and blurred vision. A retrograde postauricular island flap was harvested to provide skin eyelid coverage, and the donor site was directly closed. After another 2 surgeries, normal skin thickness and a color-matched appearance were achieved, and the donor-site scar was almost invisible from the anterior view. To our knowledge, it is rare to use a retrograde postauricular island flap in a full-thickness reconstruction of both the upper and lower eyelids, but the authors have ascertained that this method may be a reliable option in such selected and challenging situations.

Broad Tip Modification in Asian Patients Undergoing Rhinoplasty Using the Low-Lateral Cartilage Cruciate Overlap Technique.

IMPORTANCE: Asian patients undergoing cosmetic rhinoplasty often want surgeons to concentrate on the broad nasal tip. Modifying the cartilage framework is considered to be the fundamental strategy; during the modification procedures, the cephalic portion of the lower lateral cartilage is often excised and discarded. However, given the supporting function and volumetric filling properties of autologous cartilage, the cephalic cartilage should and can be salvaged by using our cruciate overlap technique. OBJECTIVES: To introduce a novel technique in modification of broad nasal tip in Asian patients undergoing rhinoplasty and assess its efficacy and safety. DESIGN, SETTING, AND PARTICIPANTS: Dissection of 5 fresh cadaver head specimens was performed and the plausibility and reliability of the new procedure were determined at Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. In addition, the cruciate overlap technique was performed in 43 Chinese patients between January 1, 2011, and December 31, 2013, and the surgical results were assessed subjectively and objectively during the follow-up period, ranging from 12 to 36 months, with the final follow-up November 30, 2014. Anthropometric measurements of patients' noses preoperatively and postoperatively were taken and the patients' complications were reviewed. MAIN OUTCOMES AND MEASURES: Cadaveric evaluation, subjective and objective assessments of the surgical results (rated on a scale of 1 to 4, with 4 indicating much improvement from the preoperative level), nasal measurements of the patients, and evaluation of the complications. RESULTS: The mean size of the cartilaginous flap in the cruciate overlap technique was 12.0 mm long and 3.0 mm wide, allowing for 180° rotation and graft coverage, with the nasal cartilage framework protected from collapse. Mean (SD) scores for the subjective and objective judgment of the outcomes were 3.3 (0.4) and 3.5 (0.3), respectively. Moreover, nasal measurements demonstrated significant postoperative improvement by increasing the mean nasal tip protrusion (from 14.3 [1.5] to 16.7 [2.0] mm) and reducing the mean tip width (from 22.7 [1.7] to 18.2 [1.6] mm) and tip angle (from 101.0° [6.3°] to 87.7° [6.7°]) (all P < .001). Acceptable ranges of edema, ecchymosis, and pain were observed in the early postoperative period and resolved within a short period. No aesthetic or functional adverse effects were reported during the follow-up period. CONCLUSIONS AND RELEVANCE: The cruciate overlap technique is an efficacious and reliable alternative for modification of broad nasal tips in Asian patients undergoing rhinoplasty. LEVEL OF EVIDENCE: 4.

Aesthetic sideburn reconstruction with an expanded reversed temporoparieto-occipital scalp flap.

The sideburn is an important feature of the facial profile in both women and men. Scars in the area around the sideburn and temple are difficult to conceal. Sideburn reconstruction is an especially challenging procedure for plastic surgeons because of the difficulty involved in acquiring high-quality tissue and achieving proper hair direction for a satisfactory appearance. This article describes how to utilize an expanded temporoparieto-occipital scalp flap for sideburn reconstruction, which results in satisfactory hair direction, inconspicuous scars in both the donor and recipient areas, and few complications. From August 2011 to April 2012, 11 patients underwent sideburn reconstruction treatments that involved the use of an expanded temporoparieto-occipital scalp flap. The likeness of hair color and density in the sideburn area was achieved, and the scars at the donor site were hidden in the post-auricular hairline. All of the patients were shown a satisfactory appearance, with few complications both on the recipient and donor site. An expanded temporoparieto-occipital scalp flap is an ideal flap to utilize in sideburn reconstructions because it results in satisfactory hair direction, inconspicuous scars at both the donor and recipient areas, and few complications.