Correction of nasal tip deformity using an island flap of nasal dorsum

Bifid nose is a rare congenital malformation, and few cases have been reported due to its low incidence. Herein, we report a new surgical procedure to treat patients with excess dorsal nasal tissue and an underfilled tip. A total of 22 patients with bifid nose deformities underwent surgery at our institution between 2012 and 2022. They were characterized by a broad nasal dorsum and a missing or underdeveloped nasal tip. We designed an innovative island flap of nasal dorsum as a new surgical method for treating this bifid nose deformity. Nasal length, tip projection, and photographs of nose morphology were obtained before and after the surgery. Outcomes, complications, indications, and patient satisfaction were analyzed and interviewed. The follow-up time ranges from 6 to 33 months (8.7 ± 5.5 months). The deformity was successfully corrected with an improved nasal appearance. Nasal length increased from initially 4.2 ± 0.3 mm to 4.6 ± 0.3 mm. Tip projection reached 19.9 ± 4.0 mm, which was 15.7 ± 2.9 mm before surgery. No severe complications were observed except poor venous reflux within postoperative 72 hours in four cases. Six patients (27.3%) got moderate healing and acceptable scars, and 14 patients (63.6%) got good healing. Most patients were very satisfied with the outcome (93.9%). The newly designed nasal dorsum island flap is a safe and effective technical approach to correct nose deformity featured by broad nasal dorsum and a missing or underdeveloped nasal tip.

Risk Factors for Locoregional Recurrence and Distant Metastasis in 143 Patients with Adenoid Cystic Carcinoma of the External Auditory Canal

AIMS

Adenoid cystic carcinoma (ACC) grows slowly and is characterised by potential recurrence and metastasis to distant organs. This study aimed to evaluate the risk factors for locoregional recurrence (LRR) and distant metastasis in patients with ACC of the external auditory canal (EAC).

MATERIALS AND METHODS

Demographic, pathological, therapeutic and survival data of 143 patients with EAC ACC were reviewed in this study. Univariate and multivariate Cox proportional hazard regression analyses were carried out to determine the risk factors for LRR and distant metastasis. Factors associated with overall survival after LRR and distant metastasis were also analysed.

RESULTS

During a median follow-up of 49 months, 31 of 143 patients were observed with LRR and 34 developed distant metastasis. Bone invasion and histological subtype were independent risk factors for locoregional recurrence-free survival. T stage and LRR were independent risk factors for distant metastasis-free survival. Salvage surgery and adjuvant radiotherapy or chemoradiotherapy for LRR resulted in better survival, whereas extrapulmonary metastasis and LRR were associated with a higher risk of poor survival after distant metastasis.

CONCLUSION

Patients with distant metastases, especially those with LRR, are at significant risk of poor prognosis. Our findings emphasise the importance of long-term regular follow-up and recommend surgical intervention with radiotherapy for recurrent EAC ACC.

Two novel mutations within FREM1 gene in patients with bifid nose

BACKGROUND

Bifid nose is a rare congenital deformity and the etiology is unknown. The purpose of this study was to report genetic variation in family of patients with bifid nose.

METHODS

Twenty-three consecutive patients who were diagnosed with mild bifid nose were operated with z-plasty from 2009 to 2021. Three underage patients (a pair of twins and a girl) from two family lines, who came to our hospital for surgical treatment, were enrolled. Whole exome sequencing and Sanger sequencing were conducted. Z-shaped flaps were created and the cartilago alaris major were re-stitched. Photographs and CT scan before and after surgery were obtained. Clinical outcomes, complications and patients' satisfaction were evaluated and analyzed. The follow-up time ranges from 2 to 3 years (2.4 ± 1.2 years).

RESULTS

Most patients were satisfied with the outcome (96.2%). The nasal deformities were corrected successfully with z-plasty technique in one-stage. FREM1 c.870_876del and c.2 T > C were detected with Whole exome sequencing, which have not been reported before. The results of Sanger sequencing were consistent with those of Whole exome sequencing.

CONCLUSIONS

The newly detected mutations of FREM1 have a certain heritability, and are helpful to make an accurate diagnosis and provide a better understanding of bifid nose mechanism. Z-plasty technique can be an effective technical approach for correcting mild bifid nose deformity.

Lateral Osteotomy for the Surgical Treatment of the Asian Wide Nose

OBJECTIVE

Narrowing of the nasal dorsum allows for a more pleasing moderate width. We here introduce a lateral osteotomy technique that is less traumatic and easier to perform than commonly used procedures in Asian and share our experiences in the application.

METHODS

After a blunt dissection of the periosteum at the mucosal side of the nasal bone, all patients who underwent treatment using nasal osteotomy at the level of the maxillary nasal process were retrospectively analyzed. The bony nasal width, height, and the nasal lateral wall slope of bone before and after surgery were measured. The postoperative outcomes, complications, and patient satisfaction were analyzed and evaluated.

RESULTS

From January 2008 to January 2018, nasal dorsum narrowing was implemented in 106 patients. On average, nasal width was significantly decreased and no change in nose height after the nasal osteotomy. The nasal width was significantly reduced by 8.51 ± 2.16 mm compared with before surgery. The slope of the nasal lateral wall was reduced from the mean of 155.0 ± 7.63-degree preoperation to the mean of 135.25 ± 7.50-degree postoperation. The follow-up period ranged from 6 months to 4 years, with an average of 10.3 months.

CONCLUSIONS

This type of nasal bone base osteotomy is a simple and feasible method for the treatment of wide Asian noses with a high patient acceptance and stable postoperative results.

LEVEL OF EVIDENCE

Level IV.

Bioengineered human tissue regeneration and repair using endogenous stem cells

We describe a general approach to produce bone and cartilaginous structures utilizing the self-regenerative capacity of the intercostal rib space to treat a deformed metacarpophalangeal joint and microtia. Anatomically precise 3D molds were positioned on the perichondro-periosteal or perichondral flap of the intercostal rib without any other exogenous elements. We find anatomically precise metacarpal head and auricle constructs within the implanted molds after 6 months. The regenerated metacarpal head was used successfully to surgically repair the deformed metacarpophalangeal joint. Auricle reconstructive surgery in five unilateral microtia patients yielded good aesthetic and functional results. Long-term follow-up revealed the auricle constructs were safe and stable. Single-cell RNA sequencing analysis reveal early infiltration of a cell population consistent with mesenchymal stem cells, followed by IL-8-stimulated differentiation into chondrocytes. Our results demonstrate the repair and regeneration of tissues using only endogenous factors and a viable treatment strategy for bone and tissue structural defects.

Reconstruction of the shortened columella in mild bifid nose using a propeller flap based on the nasal columella artery

Bifid nose generally appears short columellar and lacks the nasal tip. Here, we describe a surgical correction technique for correcting the short columellar and nasal tip of bifid nose using a local flap to discuss outcomes, patient selection, and complications based on 11 years of experience. Thirty-two patients with mild wide bifid nose and shortened columella were included in this retrospective study. All patients underwent nasal rhinoplasty using a propeller flap based on the nasal columella artery. Nasal columella length, horizontal distance of tip-defining point, and angle of facial convexity were evaluated based on three-dimensional simulation technology. Complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey. Nasal esthetics and function were considerably improved. Follow-up examinations during a period of 9 months on average demonstrated stable results. The columella length was 9.7 ± 4.6 mm preoperatively and 19.9 ± 3.2 mm postoperatively (P < 0.05). The horizontal distance of tip-defining point (mm) decreased to 18.9 ± 5.5 mm postoperatively from a preoperative 23.3 ± 5.4 mm (P < 0.05). There were no severe postoperative complications. Complications were scar, temporary hematoma, and mild infection of nasal skin. The majority of patients (97%) rated their outcome as improved and much improved. Surgical correction using a nasal columella artery propeller flap is an effective therapeutic approach for patients with mild bifid nose. The use of a local flap along with minimal donor-site morbidity and reliable outcomes contributes to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

[Correction model of the sampling time error on the blood trough concentration of tacrolimus in non-sustained-release dosage form for renal transplant recipients]

Objective: To establish correction model of the sampling time error on the blood trough concentration of tacrolimus in non-sustained-release dosage form for renal transplant recipient and improve the accuracy of drug dose assessment and clinical adjustment in renal transplant recipients. Methods: Visit records of 206 outpatients in the Department of Transplantation, Nanfang Hospital, Southern Medical University were retrospectively collected from October 15, 2022 to October 30, 2022. The distribution of sampling time of tacrolimus blood drug concentration was described and the time range of correction was determined. Twenty inpatients after renal transplantation in the Department of Transplantation, Nanfang Hospital, Southern Medical University from October 1, 2022 to November 30, 2022 were prospectively included, and their demography data, laboratory test results during follow-ups, and CYP3A5 genotype were collected. The patients took tacrolimus in non-sustained-release dosage form every 12 h starting from 19∶30 on the day of admission. Peripheral blood samples were collected from the patients on the second day of admission at 7∶30 and on the third day at 6∶00-10∶00 every 30 minutes to test the blood concentration of tacrolimus. Using the collection time as the independent variable and the blood tacrolimus concentration as the dependent variable, a simple linear regression was performed to fitting a linear model of tacrolimus blood concentration-sampling time. Multiple linear regression was performed to analyze the influencing factors of the tacrolimus metabolic rate within a specific period and generate the regression equation. Results: The 206 outpatients aged (46±13) years, including 131 males (63.6%). The time gap [M (Q₁, Q₃)] between the sampling time of the follow-up outpatients and standard C₁₂ was 24 (13.0, 46.5) min, and the maximum time gap was 135 min. The 20 enrolled inpatients aged (45±12) years, including 15 males (75.0%). There was no significant difference in the blood concentration of tacrolimus collected at 7∶30 on the second (7.87±2.21)ng/ml and third days (7.84±2.33)ng/ml after admission of the enrolled inpatients (P=0.917), and the blood tacrolimus concentration rhythm was stable in the trial. The plasma concentration of C_10.5-C_14.5 was linearly related to the time, with R² [M (Q₁, Q₃)] 0.88 (0.85, 0.92) and all P<0.05. The metabolic rate of tacrolimus during C_10.5-C_14.5=0.984+0.090×basic concentration of tacrolimus (ng/ml)-0.036×body mass index+0.489×CYP3A5 genotype-0.007×hemolobin(g/L)-0.035×alanine aminotransferase (U/L)+0.143×total cholesterol (mmol/L)+0.027×total bilirubin (μmol/L), with R²=0.85. Conclusion: This study propose a correction model for tacrolimus (non-sustained-release dosage form) trough concentration around C₁₂, which is helpful for clinicians to easily and accurately assess renal transplant recipients' tacrolimus exposure.

Repair of Scars and Tissue Deficiency With Free Grafts of Full-thickness Scalp in Secondary Unilateral Cleft Lip Deformity

Although surgical techniques have developed, the incidence of secondary cleft lip deformities after the primary repair is still high. Asymmetry of Cupid's bow and philtrum is a common presentation and a technical challenge to reconstruct the upper lip. The authors introduce a technique to use the free grafts of the full-thickness scalp for the correction of scars and tissue deficiency in secondary unilateral cleft lip deformity. Thirty-seven patients with a prominent scar, tight upper lip, deformed Cupid's bow and philtrum, and irregular vermillion border were included in this study. The specific points of interest were assessed before and after surgery by independent examiners with both subjective and objective methods. All surgeries were successfully completed, and the assessment results were satisfactory. The rating scores of philtrum improvement was 1.6±0.4, the POSAS result of patient scales was 13.48±3.21, and the observer scale result was 11.98±3.88. The asymmetry of Cupid's bow was corrected (P=0.004), the central tubercle of vermilion was more natural (P=0.001), and the irregular vermillion border was improved (P=0.015). The results presented significant differences before and after surgery. This method could be an optional treatment for repairing scars and tissue deficiency in secondary unilateral cleft lip deformity.

Differential Expression of Autophagy-Related Long Non-Coding RNA in Melanoma

To explore the role of autophagy-related differential long non-coding RNA (lncRNA) in the pathogenesis of melanoma, we established a prognostic prediction model for patients with melanoma based on the expression profiles of autophagy-related gene. Based on The Cancer Genome Atlas and GeneCard database, we used single-sample gene set enrichment analysis (ssGSEA), weighted gene co-expression network analysis (WGCNA), uniCOX in R software for COX proportional hazard regression analysis, and enrichment analysis to get an idea of biological processes with autophagy-related genes, which evaluates the relationship between autophagy-related genes and immune cell infiltration in patients with melanoma. The roles of identified lncRNA were evaluated by the risk score based on the results of single factor regression analysis for each lncRNA and on the prognosis for patients obtained from the database. Then, the whole sample was divided into high- and low-risk groups. Survival curve analysis showed that low-risk group had a better prognosis. Enrichment analysis revealed multiple key pathways enriched with lncRNA-associated genes. Analysis of immune cell infiltration revealed differences between high- and low-risk groups. Finally, 3 datasets verified the effect of our model on prognosis. There are important autophagy-related lncRNA in patients with melanoma. Top 6 lncRNA are significantly related to the overall survival rate of patients with melanoma and provide the basis for predicting the prognostic survival of patients.

Surgical Correction of a Bifid Nose Deformity with a Split M-Shaped Flap

Background: Bifid nose is a representative indicator of a facial cleft in patients with frontonasal dysplasia. There is no consensus on effective methods to correct bifid nose deformities due to their varied expressions and limited reports of surgical treatments. In this article, we propose using a split M-shaped flap to treat severe dorsal and alar deformities in patients with a bifid nose. Methods: From 2012 to 2021, a total of 26 bifid nose patients underwent surgical correction of their nasal deformities, which were characterized by cleft and board dorsum, alar defects, shortened nose, and shortened or absent nasal tip. These surgeries were performed with the transposition of an M-shaped split flap. Nasal length and nasolabial angle were assessed before and after surgery. Indications, outcomes, and complications were analyzed. Patient satisfaction was evaluated using a self-assessment survey. Results: Postoperative evaluation showed stable results with increased nasal length and improved nasal appearance. Complications were seen in difficulty breathing through the nose and persistent nostril deformities. The majority of patients (92.3%) were satisfied with their surgical outcome. Conclusion: Split M-shaped flap for bifid nose treatment provides improved nasal appearance with a high patient acceptance and stable postoperative results. Clinical Trial registration: chictr.org identifier ChiCTR2000039275.

Progress of Periosteal Osteogenesis: The Prospect of In Vivo Bioreactor

Repairing large segment bone defects is still a clinical challenge. Bone tissue prefabrication shows great translational potentials and has been gradually accepted clinically. Existing bone reconstruction strategies, including autologous periosteal graft, allogeneic periosteal transplantation, xenogeneic periosteal transplantation, and periosteal cell tissue engineering, are all clinically valuable treatments and have made significant progress in research. Herein, we reviewed the research progress of these techniques and briefly explained the relationship among in vivo microenvironment, mechanical force, and periosteum osteogenesis. Moreover, we also highlighted the importance of the critical role of periosteum in osteogenesis and explained current challenges and future perspective.

P–568 Homozygous Pathogenic Variants in ACTL9 Cause Fertilization Failure and Male Infertility in Human and Mouse

Study question

What are the other male factors that cause total fertilization failure (TFF) excepting for variants in PLCZ1?

Summary answer

Homozygous variants in ACTL9 (actin like 9) cause abnormal localization of PLCζ in a loosened perinuclear theca (PT) structure and leads to TFF.

What is known already

In previous studies, investigators have reported that the female factors in TFF after intracytoplasmic sperm injection (ICSI) include pathogenic variants in WEE2, TLE6, and TUBB8, whereas for male factors, pathogenic variants in PLCZ1 were reported to be the primary cause of TFF, which account for approximately 30% of couples with male factors in TFF excluding globozoospermia. Most recently, it was reported that pathogenic variants in ACTL7A led to reduced expression and abnormal localization of PLCζ, thereby identifying this genetic variant as a potential cause of TFF.

Study design, size, duration

Fifty-four infertile couples with TFF or poor fertilization (fertilization rate of &lt; 20%) at the Reproductive and Genetic Hospital of CITIC-Xiangya during January 2014 to June 2020 were recruited into this study.

Participants/materials, setting, methods

Male factors were identified in (MOAT). WES analysis was used to analyze the genetic factors of individuals with male factors. Sperm morphological study was conducted by H&E staining and TEM. Immunostaining of PLCζ was used to analyze the status of sperm-borne activation factor. A knock-in mouse model was generated by CRISPER-Cas9 technology. Sperm from homozygous Actl9 variant mice were analyzed by TEM and ICSI. ICSI with AOA was performed in couples with ACTL9 variants.

Main results and the role of chance

A total of 54 couples with TFF or poor fertilization were screened, with 21 couples determined to have a male infertility factor by MOAT. Whole-exome sequencing of these 21 male individuals identified three homozygous pathogenic variants in ACTL9 in three individuals. ACTL9 variations led to abnormal ultrastructure of the PT, with PLCζ absent in the head and present in the neck of the mutant sperm, which contributed to failed normal calcium oscillations in oocytes and subsequent TFF. The key roles of ACTL9 in the PT structure and TFF after ICSI were further confirmed in Actl9-mutated mouse model. Furthermore, assisted oocyte activation by calcium ionophore exposure successfully overcame TFF and achieved live births in a couple with an ACTL9 variant.

Limitations, reasons for caution

The mechanism of how ACTL9 regulate PLCζ remains unknown.

Wider implications of the findings: It provided a genetic marker and a therapeutic option for individuals who have undergone ICSI without successful fertilization.

Trial registration number

not applioable

EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction - a Scandinavian case series

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metallic stents (LAMS) in patients with gastric outlet obstruction (GOO) has proven to be an alternative to luminal stenting in the duodenum and surgical gastroenterostomy. In severely ill patients, the method can provide improved quality of life (QoL) and symptom relief by restoration of the luminal passage of fluid and nutrients to the small intestine.

AIM

To assess the technical and clinical success and safety of EUS-GE.

MATERIAL AND METHODS

A dual center retrospective case series of 33 consecutive patients with GOO due to malignant (n = 28) or non-malignant conditions (n = 5). The patients were treated with EUS-GE using cautery enhanced LAMS. Procedures were performed guided by EUS and fluoroscopy in general anesthesia or conscious sedation.

RESULTS

Technical success was achieved in all patients. The median procedure time was 71 min and the median hospital stay was three days. Thirty (91%) patients were able to resume oral nutrition after the procedure. Ten patients (30%) experienced adverse events (AEs), including migration of the stent, bleeding, and infection. Four patients had fatal AEs (12%). All stent-related AEs were handled endoscopically. Five patients (15%) needed re-intervention. The median survival time for patients with malignant obstruction was 8.5 weeks (0.5-76), and 13 patients with obstructing malignancies lived 12 weeks or longer.

CONCLUSION

EUS-GE is a minimally invasive and efficient method for restoration of the gastrointestinal passage and may improve palliative care for patients with GOO. The method has potential hazards and should only be offered in expert centers that regularly perform the procedure.

A compact electron beam ion trap in support of high-temperature plasma diagnostics based on conduction-cooled superconducting coils

Spectroscopic diagnostics of future fusion reactor plasmas require information on impurity line emissions, especially for relevant high-Z metal elements (e.g., tungsten). These materials will be widely used as plasma facing components for their high heat tolerance and low sputtering yield. Based on an electron beam ion trap, a compact impurity spectra platform is developed to mimic the high-temperature environment of a fusion reactor. The proposed platform can deliver a focused e-beam at energies over 30 keV using a confining magnetic field of ∼1.0 T generated by two superconducting coils (NbTi). Cooled by a closed-loop cryocooler, the coils can avoid the usage of a complicated cryogenic system involving the handling of liquid helium. For spectroscopic studies of highly charged ions, a spherically curved crystal spectrometer is proposed to measure a wavelength range around 2-4 Å covering the typical wavelength range expected to be emitted by metal ions in a fusion plasma. This paper reports the design and development progress of the platform.

Assessing adaptation measures on agricultural water productivity under climate change: A case study of Huai River Basin, China

This study explored an integrated framework to assess the effectiveness of adaptation measures on the water productivity (WP) of the agricultural water management (AWM) system in the Huai river basin of China considering climate change impact. The adaptation measures include optimization of cropping pattern (OCP) and upgradation of irrigation techniques (UIT). The delta change method was used to downscale the climate variables from RCP4.5 and RCP8.5 of general circulation models (GCMs) during 2021-2050, the water footprint theory was used to estimate the spatial distribution of blue water to calculate the WP, and the nonlinear optimization model was used to seek optimal cropping pattern aiming at maximizing the system's WP. The changes in WP due to climate change and adaptation measures (e.g. combinations of OCP and UIT) were compared. Results indicated that WP under RCP4.5 and RCP8.5 would be 4.56% and 6.51% lower than those under the benchmark scenario, respectively. The mitigation rates to the negative impact of climate change on WP under RCP4.5 and RCP8.5 would be (1) 3.05% and 3.37% for the combination of spay irrigation technique and OCP, and (2) 4.34% and 4.59% for the combination of drip irrigation technique and OCP, respectively. It was revealed that the combination of drip irrigation and cropping pattern optimization could largely offset the adverse effect from climate change on WP under RCP4.5. Under such a scenario, the total plant areas of wheat and maize would reduce over the basin and so would the net export of crops in the basin; this would lead to a decrease in the crop trade benefit of 7.07 × 10⁹ $ and a relief of 7.50 × 10⁹ m³ of blue water loss. This study results could offer strategic decision support for long-term sustainable AWM of Huai river basin in a changing environment.

Short term results of philtrum reconstruction with an orbicularis oris muscle flap in cleft patients

PURPOSE

In the treatment of philtral ridge deficiency in cleft lip patients, optimal results are difficult to obtain due to visible scarring following surgery. The purpose of this article is to introduce a novel strategy for philtrum reconstruction along with an evaluation of postoperative outcomes of this technique.

METHOD

All patients with a deficiency of the philtrum underwent reconstruction of the philtral ridge and upper lip using an orbicularis oris muscle flap with a specific re-suturing technique in our study. The convexity of the philtral ridge was evaluated pre- and postoperatively at rest and while puckering using patient photography as well as three-dimensional simulation technology. Postoperative outcomes and complications were assessed during follow-up, including a patient satisfaction survey.

RESULTS

Thirty cleft lip patients underwent treatment in this study using a specific orbicularis oris muscle re-suturing technique. The average age of the 13 male and 17 female patients was 31.5 years. The follow-up period ranged from 6 months to 3.5 years with an average of 10.3 months. Postoperative results showed an aesthetic reconstructed philtral ridge with stable outcome. Complications included acute infection (1 case) and temporary stiffness of smile (3 cases). No systemic complications occurred. All patients were satisfied with their results, and none required further surgery.

CONCLUSION

We propose a simple, effective, and reproducible technique involving an orbicularis oris muscle flap for the creation of the philtral column in secondary cleft lip deformity. Our approach allowed aesthetically pleasing and stable outcomes. Although the short-term results of the philtrum reconstruction seem to be adequate there is no information on the long-term situation, and therefore no general recommendation to adopt this method can be given.