The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Combination of acellular dermal matrix with a de-epithelialised dermal flap during skin-reducing mastectomy and immediate breast reconstruction.

Introduction Patients with large ptotic breasts undergoing immediate implant-based reconstruction often require skin-reducing mastectomy to optimise the aesthetic outcome. However, healing complications, especially at the resulting inverted T-junction, leading to wound dehiscence, infection, skin necrosis, implant exposure and failed reconstruction have been widely reported. We present an innovative approach for immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling to protect and support the implant, while improving clinical outcomes in this challenging group of patients. Materials and methods Demographic, tumour and surgical data were reviewed for patients undergoing Wise pattern (T-scar) skin-reducing mastectomies with immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling. Results This technique was successfully employed to reconstruct five large pendulous breasts in four breast cancer patients with a median age of 50.5 years (range 34-61 years) who were not suitable for, or had declined, flap-based reconstruction. The acellular dermal matrices used were SurgiMend®, StratticeTM and Braxon® and the expandable implants were placed in the sub-pectoral (n = 3) and pre-pectoral (n = 1) planes. The technical steps and clinical outcomes are presented. One patient experienced T-junction breakdown overlying the de-epithelialised dermis without implant loss. Conclusion The combination of an acellular dermal matrix and a dermal sling provides a double-layer 'water-proofing' and support for the implants inferiorly, avoiding T-junction breakdown complications, since any dehiscence is on to well-vascularised dermis. Furthermore, the acellular dermal matrix stabilises the implant in the large mastectomy cavity (pocket control). This approach provides a viable option which facilitates mastectomy and immediate implant reconstruction in large-breasted patients.

Gluteal fold flap in perineal reconstruction for Crohn's disease-associated fistulae.

INTRODUCTION: Crohn's disease is increasing in incidence worldwide. It is associated with many complications including fistulae, which may require surgical intervention. Occasionally, formal perineal reconstruction is needed for extensive or definitive fistula surgery. Reconstruction for inflammatory disease presents unique challenges and often calls for innovative solutions. Gluteal fold flaps (GFFs), which have been widely used in vulvo-vaginal malignancy and anorectal cancer surgery, have not hitherto been reported for Crohn's disease-associated fistulae. CASE PRESENTATION: A 30-year-old female presented with a 5-year history of Crohn's-associated perianal and rectovaginal fistulae. She had a previous small bowel resection and ileostomy. A laparascopic pan-proctocolectomy was carried out followed by perineal reconstruction in a single stage procedure using a pedicled fasciocutaneous GFF. Seven months postoperatively, revisional surgery was carried out using the contralateral GFF due to two areas of persistent wound dehiscence. The outcome was complete resolution of the fistulae, stable wound closure and good cosmesis. DISCUSSION & CONCLUSION: This case demonstrates that it is practical to use the GFF for perineal reconstruction following excision of complex Crohn's-associated fistulae. The flap avoids the sequelae associated with sacrifice of regional muscle flaps and specifically circumvents the unavailability of the rectus abdominis flap in slim patients or those with in-situ ileostomies. It is easy and quick to raise and does not require an intra-operative change in the patient's position. The GFF ensured well vascularised skin cover, adequate flap volume with no loss of function and low donor site morbidity.

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction.

INTRODUCTION: Chondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery. PRESENTATION OF CASE: A 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected. DISCUSSION: The outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis. CONCLUSION: This case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.

Experience with the Wise mammaplasty skin resection pattern in skin-sparing mastectomy and immediate breast reconstruction for large breast volumes.

INTRODUCTION: Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) remain technically challenging in very large breasted women, often requiring extensive skin reduction, with a high incidence of post-operative complications. We report our retrospective experience (1999-2007) with SSM and Wise pattern skin reduction in IBR, and examine factors contributing to recipient site post-operative complications. RESULTS: 29 reconstructions comprising 16 free TRAM/DIEPs, 5 pedicled TRAMs, and 8 implant-based ones were undertaken in 25 patients aged 32-70 years (median = 48). Their mean BMI was 30.4 kg/m² (r = 22.3-39.3) and 6/25 were current smokers. There were 14 (48%) associated axillary clearances. All breasts had grade 2 or 3 ptosis. The mastectomies weighed 805 g-1972 g (mean = 1326). Sixteen operations (55%) developed complications; 7 minor, 9 requiring further surgical intervention. Of these 16 cases, 13 involved skin complications and 9 involved culture-proven wound infections. All patients achieved satisfactory aesthetic outcomes. At median cancer follow-up of 24 months (r = 2-98), there have been no local recurrences but two deaths from distant metastases. Mastectomy weight was significantly associated with major skin complications requiring surgery (age-adjusted OR per 100 g = 1.6; CI = 1.1-2.3, p = 0.02). Performance of axillary clearance at the time of skin-sparing mastectomy was significantly associated with risk of post-operative infection (age-adjusted OR = 5.8; CI = 1.3-26.0, p = 0.021). These relationships were maintained after adjusting for patient, surgical and tumour factors. CONCLUSION: Wise pattern skin reduction is a useful technique for managing large, ptotic breasts during SSM and IBR. Increasing breast size and the type of cancer surgery are important predictors of post-operative complications.

Cytonuclear discordance across a leopard frog contact zone.

We conducted a genetic analysis of the extent of hybridization within and outside a contact zone between two North American leopard frogs, Rana blairi and Rana pipiens by comparing distribution patterns of mitochondrial and nuclear haplotypes. The contact zone, located between South Dakota, Nebraska, and Iowa, USA, was previously examined using morphological data in the 1970s, leading to the conclusion that hybridization was rare between R. pipiens and R. blairi. Our genetic analysis of 51 populations (611 samples) shows strong cytonuclear discordance. Mitochondrial-haplotype distribution matches the same pattern as the documented species spatial distributions based on morphology. However, the geographic distribution of the nuclear haplotypes reveals asymmetrical swamping of the R. pipiens nuclear haplotypes by R. blairi haplotypes. Phylogenetic analyses of both mitochondrial and nuclear markers provide strong evidence for the presence of R. blairi-R. pipiens introgression for the nuclear marker. A pattern of mitochondrial isolation with nuclear introgression is extremely unusual, and predicted to occur much less often than the reverse.

Cytokine gene polymorphisms in gastric cancer patients from two Italian areas at high and low cancer prevalence.

Polymorphisms of interleukin-1beta (IL-1beta), IL-1 receptor antagonist (IL1-RN), and tumor necrosis factor-alpha (TNF-alpha) genes are supposed to be key determinants of gastric cancer risk. Our aim was to study the association between these polymorphisms and gastric cancer in two areas characterized by high (Pavia/Bologna, North Italy) and low (San Giovanni Rotondo, South Italy) gastric cancer prevalence. Genomic DNA was obtained from 216 healthy donors and 98 gastric cancer patients from Pavia and Bologna, and 146 healthy donors and 86 gastric cancer patients from San Giovanni Rotondo. Two SNP in IL-1beta (-511 C/T) and TNF-alpha (-308 G/A) as well as the VNTR polymorphism of IL-1RN locus were studied. A significant linkage disequilibrium was found between IL-1beta -511 and IL-1RN. Genotype and allele frequencies at the IL-1beta, IL-1RN, and TNF-alpha loci in gastric cancer cases were not significantly different from controls. An epistatic effect between IL-1beta -511 and IL-1RN was found with the IL-1beta -511C/IL-1RN*2 haplotype conferring a significant protection against the intestinal-type of gastric cancer in the Southern population. In conclusion, IL-1beta, IL1-RN, and TNF-alpha genotypes are not associated with gastric cancer in Italian patients. An epistatic interrelationship between IL-1beta -511 and IL-1RN confers protection against gastric cancer in low-risk Italian population.

Detection of free and plankton-associated Helicobacter pylori in seawater.

AIMS: To detect both free and plankton-associated Helicobacter pylori in seawater samples collected on the Italian coast of the Adriatic Sea using a nested-PCR. METHODS AND RESULTS: Dissolved oxygen, pH, salinity and chlorophyll 'a' were the parameters recorded together with the characterization of zooplanktonic organisms. Plankton-associated H. pylori DNA was searched for in water samples filtered through 200 and 64 microm nylon nets whereas free bacteria were retained with the subsequent filtration through 0.22 microm pore-size membranes. Nested-PCR using primers for the glmM (ureC) gene was performed to reveal the presence of H. pylori. The DNA sequencing of amplified products confirmed the specificity of the assay. The sensitivity of the nested-PCR assay for H. pylori detection was 62 CFU per 100 ml in spiked water samples. Helicobacter pylori either free or bound to planktonic organisms was found in seven of 12 monthly samples. In particular, free bacteria were detected during the summer sampling and in November, December and March associated to planktonic cells. CONCLUSIONS: The presence of free and plankton-associated H. pylori in seawater suggests that it can be a significant reservoir and a potential route of transmission for the microorganism. SIGNIFICANCE AND IMPACT OF THE STUDY: Our study seems to provide a promising background to define new and effective strategies for surveillance of this human pathogen.

Population dynamics in ageing Helicobacter pylori.

The aim of this work was to characterize population changes occurring in aged broth cultures of Helicobacter pylori. Experiments were performed using clinical strains cultured immediately after isolation and after multiple subcultures in solid medium. Morphological changes in the ageing bacteria during a 7-day broth culture were analysed by optical and electron microscopy. The expression of the virulence factor, CagA, together with the presence of the cell cycle regulator, cGMP, were also assessed. The transition from bacillary to coccoid forms was the main morphological change observed in freshly isolated bacteria, together with the increase in cGMP from 1 to 2.25 nmoles/mg of proteins within the first 7 days of broth culture. A similar trend of morphological and physiological changes was observed in cells after multiple subcultures in solid medium with a major presence of large cell clusters. The cagA gene product was always expressed in all experimental conditions evaluated. These data show a significant morphological and physiological diversity in fresh, ageing and aged cultures of H. pylori.

Molecular fingerprinting of Helicobacter pylori strains from duodenal ulcer patients.

AIMS: To characterize the molecular fingerprinting of Helicobacter pylori population isolated in duodenal ulcer patients treated with triple therapy. METHODS AND RESULTS: Gastric biopsy specimens from corpus and antrum, were cultured for H. pylori isolation. Helicobacter pylori eradication was evaluated after 4 and 16 weeks. DNAs of all isolates were characterized by random amplified polymorphic DNA typing and cagA gene was also detected. After the therapy, five patients harboured the microorganism at 4 weeks and two of them remained H. pylori positive at 16 weeks. The analysis of DNA fingerprinting of strains isolated from antrum and corpus of patients susceptible to treatment, showed similar patterns. Instead, when the therapy was not effective, strains isolated from sequential biopsies from initial and after 4 and 16 weeks, showed distinct fingerprintings and retained the cagA status, over time. CONCLUSIONS: The drugs used for therapy could exercise an effect in genotypical rearrangement among H. pylori cells. SIGNIFICANCE AND IMPACT OF THE STUDY: The variableness among H. pylori strains represents a way to challenge environmental stress.

Quantitative microbial monitoring in a dental office.

The aim of this study was to evaluate the environmental pollution before and after dental procedures (during one year) in a dental office in which a system of air filtration was effective and suitable procedures of microbial controls were routinely applied for instruments and small surfaces. The air contamination was evaluated during one year by the 'plate' method (Air Microbial Index, AMI) in each room of the dental office following a bimonthly monitoring program. Nutrient agar plates were exposed, in monitored areas for 1 h for each control time and incubated at 37 degrees C for 2 days. The number of viable cells was expressed as colony forming units per plate per hour (CFU/plate/h). During the observation year, the quantitative analysis of the microbiological levels in the operative areas was always within acceptable values. In fact, a range from 4-18 CFU/plate/h was found as the mean of AMI in each controlled room. In particular, the aerosol pollution following dental procedures did not significantly modify AMI values compared with AMI values recorded before dental procedures. Data presented here demonstrate that the combined use of effective infection control procedures and a system of air filtration can be efficacious in reducing airborne environmental contamination in a dental office and emphasise the use of an inexpensive method such as AMI to verify the environmental bacterial pollution.