The transfrontal isthmus approach for insular glioma surgery

OBJECTIVE

The classic transopercular or transsylvian approach to insular gliomas removes the tumor laterally through the insular cortex. This study describes a new anteroposterior approach through the frontal isthmus for insular glioma surgery.

METHODS

The authors detailed the surgical techniques for resection of insular gliomas through the transfrontal isthmus approach. Fifty-nine insular gliomas with at least Berger-Sanai zone I involvement were removed with the new approach, and extent of resection and postoperative neurological outcomes were assessed.

RESULTS

Fifty-nine patients were enrolled in the study, including 35 men and 24 women, with a mean (range) age 44.3 (19-75) years. According to the Berger-Sanai classification system, the most common tumor was a giant glioma (67.8%), followed by involvement of zones I and IV (18.6%). Twenty-two cases were Yaşargil type 3A/B, and 37 cases were Yaşargil type 5A/B. The average angle between the lateral plane of the putamen and sagittal line was 33.53°, and the average width of the isthmus near the anterior insular point was 33.33 mm. The average angle between the lateral plane of the putamen and the sagittal line was positively correlated with the width of the isthmus near the anterior insular point (r = 0.935, p < 0.0001). The median (interquartile range [IQR]) preoperative tumor volume was 67.82 (57.64-92.19) cm3. Of 39 low-grade gliomas, 26 (66.67%) were totally resected; of 20 high-grade gliomas, 19 (95%) were totally resected. The median (IQR) extent of resection of the whole group was 100% (73.7%-100%). Intraoperative diffusion-weighted imaging showed no cases of middle cerebral artery- or lenticulostriate artery-related stroke. Extent of insular tumor resection was positively correlated with the angle of the lateral plane of the putamen and sagittal line (r = -0.329, p = 0.011) and the width of the isthmus near the anterior insular point (r = -0.267, p = 0.041). At 3 months postoperatively, muscle strength grade exceeded 4 in all cases, and all patients exhibited essentially normal speech. The median (IQR) Karnofsky performance score at 3 months after surgery was 90 (80-90).

CONCLUSIONS

The transfrontal isthmus approach changes the working angle from lateral-medial to anterior-posterior, allowing for maximal safe removal of insular gliomas.

TRIM24 promotes stemness and invasiveness of glioblastoma cells via activating Sox2 expression

BACKGROUND

Glioblastoma stem cells (GSCs) are a subpopulation of glioblastoma (GBM) cells that are critical for tumor invasion and treatment resistance. However, little is known about the function and mechanism of tripartite motif-containing 24 (TRIM24) in GSCs.

METHODS

Immunofluorescence, flow cytometry, and western blot analyses were used to evaluate TRIM24 and cluster of differentiation (CD)133 expression profiles in GBM surgical specimens and GSC tumorspheres. Different TRIM24 expression levels in patients' tumors, as measured by both immunohistochemistry and western blot, were related to their corresponding MRI data. Wound healing, Matrigel invasion, and xenograft immunohistochemistry were conducted to determine GBM cell invasion.

RESULTS

We identified that TRIM24 was coexpressed with CD133 and Nestin in GBM tissues and tumorsphere cells. Limiting dilution assays and xenotransplantation experiments illustrated that knockdown of TRIM24 expression reduced GSC self-renewal capacity and invasive growth. TRIM24 expression levels were positively associated with the volumes of peritumoral T2 weighted image abnormality. Rescue experiments indicated TRIM24 participation in GBM infiltrative dissemination. Chromatin immunoprecipitation, reporter gene assay, PCR, western blot, and immunohistochemistry demonstrated that TRIM24 activated the expression of the pluripotency transcription factor sex determining region Y-box 2 (Sox2) to regulate GBM stemness and invasion in vitro and in vivo. Finally, the close relationship between TRIM24 and Sox2 was validated by testing samples enrolled in our study and exploring external databases.

CONCLUSIONS

Our findings uncover essential roles of the TRIM24-Sox2 axis in GBM stemness and invasiveness, suggesting TRIM24 as a potential target for effective GBM management.

Identification of risk factors for poor language outcome in surgical resection of glioma involving the arcuate fasciculus: an observational study

The arcuate fasciculus is a critical component of the neural substrate of human language function. Surgical resection of glioma adjacent to the arcuate fasciculus likely damages this region. In this study, we evaluated the outcome of surgical resection of glioma adjacent to the arcuate fasciculus under the guidance of magnetic resonance imaging and diffusion tensor imaging, and we aimed to identify the risk factors for postoperative linguistic deficit. In total, 54 patients with primary glioma adjacent to the arcuate fasciculus were included in this observational study. These patients comprised 38 men and 16 women (aged 43 ± 11 years). All patients underwent surgical resenction of glioma under the guidance of magnetic resonance imaging and diffusion tensor imaging. Intraoperative images were updated when necessary for further resection. The gross total resection rate of the 54 patients increased from 38.9% to 70.4% by intraoperative magnetic resonance imaging. Preoperative language function and glioma-to-arcuate fasciculus distance were associated with poor language outcome. Multivariable logistic regression analyses showed that glioma-to-arcuate fasciculus distance was the major independent risk factor for poor outcome. The cutoff point of glioma-to-arcuate fasciculus distance for poor outcome was 3.2 mm. These findings suggest that intraoperative magnetic resonance imaging combined with diffusion tensor imaging of the arcuate fasciculus can help optimize tumor resection and result in the least damage to the arcuate fasciculus. Notably, glioma-to-arcuate fasciculus distance is a key independent risk factor for poor postoperative language outcome. This study was approved by the Ethics Committee of the Chinese PLA General Hospital, China (approval No. S2014-096-01) on October 11, 2014.

[Implement of multimodal navigation-based virtual reality in the needle biopsy of intracranial eloquent lesions]

Objective: To investigate the clinical value of multimodal navigation-based virtual reality (MNVR) in the needle biopsy of intracranial eloquent lesions. Methods: From January 2016 to January 2017, 20 patients with intracranial deep-seated lesions involving eloquent brain areas underwent MNVR-aided needle biopsy at Department of Neurosurgery, People's Liberation Army General Hospital. Preoperatively, MNVR was used to propose and revise the biopsy planning. Intraoperatively, navigation helped trajectory avoid the eloquent structures. Intraoperative MRI (iMRI) was performed to prove the biopsy accuracy and detect the intraoperative complications. Perioperative neurological status, iMRI findings, intraoprative complications, surgical outcome and pathological diagnosis were recorded. Wilcoxon rank-sum test was conducted to compare the preoperative and postoperative neurological scores. Results: MNVR helped revised 45%(9/20) initial biopsy trajectories, which would probably injury the nearby eloquent structures. Navigation helped biopsy trajectories spare the eloquent structures during the operation. No statistical difference was found between postoperative and preoperative neurological status, despite all the lesions were adjacent to eloquent areas. Additionally, 20 patients totally received 21 iMRI scanning. iMRI helped revise incorrect biopsy site in one case and detected intraoperative hemorrhage in another case, both of cases were treated immediately and effectively. No MNVR related adverse events and complications occurred. Conclusions: MNVR-aided needle biopsy of intracranial eloquent lesions is a safe, novel and efficient biopsy modality. This technique is helpful to reduce the incidence of surgery related neurological deficits.

Intraoperative visualisation of functional structures facilitates safe frameless stereotactic biopsy in the motor eloquent regions of the brain

BACKGROUND

For stereotactic brain biopsy involving motor eloquent regions, the surgical objective is to enhance diagnostic yield and preserve neurological function. To achieve this aim, we implemented functional neuro-navigation and intraoperative magnetic resonance imaging (iMRI) into the biopsy procedure. The impact of this integrated technique on the surgical outcome and postoperative neurological function was investigated and evaluated.

METHOD

Thirty nine patients with lesions involving motor eloquent structures underwent frameless stereotactic biopsy assisted by functional neuro-navigation and iMRI. Intraoperative visualisation was realised by integrating anatomical and functional information into a navigation framework to improve biopsy trajectories and preserve eloquent structures. iMRI was conducted to guarantee the biopsy accuracy and detect intraoperative complications. The perioperative change of motor function and biopsy error before and after iMRI were recorded, and the role of functional information in trajectory selection and the relationship between the distance from sampling site to nearby eloquent structures and the neurological deterioration were further analyzed.

RESULTS

Functional neuro-navigation helped modify the original trajectories and sampling sites in 35.90% (16/39) of cases to avoid the damage of eloquent structures. Even though all the lesions were high-risk of causing neurological deficits, no significant difference was found between preoperative and postoperative muscle strength. After data analysis, 3mm was supposed to be the safe distance for avoiding transient neurological deterioration. During surgery, the use of iMRI significantly reduced the biopsy errors (p = 0.042) and potentially increased the diagnostic yield from 84.62% (33/39) to 94.87% (37/39). Moreover, iMRI detected intraoperative haemorrhage in 5.13% (2/39) of patients, all of them benefited from the intraoperative strategies based on iMRI findings.

CONCLUSIONS

Intraoperative visualisation of functional structures could be a feasible, safe and effective technique. Combined with intraoperative high-field MRI, it contributed to enhance the biopsy accuracy and lower neurological complications in stereotactic brain biopsy involving motor eloquent areas.

Image-guided endoscopic surgery for spontaneous supratentorial intracerebral hematoma

OBJECTIVE Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas. METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient's scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma. RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40-70 minutes). The actual endoscopic operating time was 30 (range 15-50) minutes. The median blood loss was 80 (range 40-150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01). CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma's location to achieve satisfactory hematoma removal.

Facial and Cochlear Nerve Complications following Microsurgical Resection of Vestibular Schwannomas in a Series of 221 Cases

Background

Despite improvements in microsurgical technique and the use of intraoperative electrophysiological monitoring, the potential for facial and cochlear nerve injury remains a possibility in the resection of vestibular schwannomas (VS). We reviewed a series of 221 cases of VS resected via a retrosigmoid approach at our institution from October 2008 to April 2014 and determined the incidence of postoperative facial and cochlear deficits.

Material/Methods

A total of 221 patients – 105 (47.5%) male and 116 (52.5%) female – with a mean age of 46.1 years (range 29–73 years), with VS ≥3 cm (n=183, 82.8%) and <3 cm (n=38, 17.2%) underwent surgical resection via a retrosigmoid approach and were evaluated for postoperative facial and cochlear nerve deficits.

Results

Near-total resection (>95% removal) was achieved in 199 cases (90%) and subtotal resection (>90% removal) in 22 cases (10%). At 6 month follow-up, House-Brackmann grades I–III were observed in 183 cases (82.8%), grade IV in 16 cases (7.2%), and grade V in 22 cases (10%). Of the 10 patients that had preoperative functional hearing, 3 (33%) retained hearing postoperatively. Cerebrospinal fluid leakage occurred in 6 patients (2.7%), lower cranial nerve palsies in 9 patients (4.1%), and intracranial hematomas 3 cases (1.4%).

Conclusions

The observed incidence of persistent postoperative nerve deficits is very low. Meticulous microsurgical dissection of and around the facial and cochlear nerves with the aid of intraoperative electrophysiological nerve monitoring in the retrosigmoid approach allows for near-total resection of medium and large VS with the possibility of preservation of facial and cochlear nerve function.

Synthesis and antimicrobial activity of 9-o-substituted palmatine derivatives

A series of new palmatine derivatives with alkyl or alkyl with N-heterocyclic structures were designed and synthesized at C-9-O according to the principle of association. These compounds were characterised by ¹H NMR, ¹³C NMR, ESI-MS and elemental analysis, and tested for their antimicrobial activity in vitro to evaluate structure-activity relationships. The results indicated that 9-O-substituted palmatine derivatives exhibit varying degrees of antimicrobial activity. Antibacterial activities of compounds (3a-f) against Gram +ve bacteria increased 2- to 64-fold than that of palmatine. The compounds (3a-f) possessed relatively weaker inhibitory effects against Gram −ve bacteria and fungi than that against Gram +ve bacteria. Antimicrobial activities of compounds (5a-e) are lower than that of compounds (3a-f). Compound 3d showed the highest antimicrobial activity of all the compounds. The LD₅₀ values of compounds (3a-f) decreased as the alkyl side chain was elongated. Compound 3f showed least toxicity.

[Application of diffusion tensor imaging-based arcuate fasciculus tractography and intraoperative arcuate fasciculus navigation]

OBJECTIVE

To investigate the feasibility of applying diffusion tensor imaging (DTI)-based arcuate fasciculus tractography and intraoperative arcuate fasciculus navigation for neurosurgery.

METHODS

Totally 85 patients with interhemispheric tumors who had undergone intra-operative magnetic resonance imaging (MRI) and neuronavigation were divided into sinistrocerebral tumor (SCT) group (n = 55) and sham group (n = 30). All patients accepted routine MRI and DTI preoperatively. The results from both DTI-based arcuate fasciculus tractography and neuronavigation were applied to guide the surgery. All patients were followed up at 2-4 weeks and 3-6 months postoperatively.

RESULTS

All patients smoothly received the pre-operative DTI-based arcuate fasciculus tractography. The three dimensional arcuate fasciculus was successfully integrated with the neuronavigation and achieved microscope heads-up display. Long-term follow-up showed that there were only 4 patients suffered from persistent language dysfunction.

CONCLUSIONS

The combined application of DTI-based arcuate fasciculus tractography and intraoperative arcuate fasciculus navigation is feasible for guiding brain surgery. It can improve the surgical outcomes of intracranial tumor involving language functional area. The technology also maximizes the retention of language function and improves the post-operative quality of life.

First Report of Anthracnose of Digitaria sanguinalis Caused by Colletotrichum hanaui in China

Hairy crabgrass (Digitaria sanguinalis (L.) Scop.) is a troublesome weed in most agricultural crops worldwide. Considerable efforts are made to limit the invasiveness and impact of crabgrass on crop productivity, including evaluation of fungi as biocontrol agents (3). In September 2005, a severe disease was observed on crabgrass plants in Zhejiang Province. Leaves and stems of the affected plant showed small, water-soaked, brownish spots that rapidly turned into longitudinal elliptic or spindle-shaped lesions, 6.5 to 8 × 22 to 24 mm, with a brown outer edge and a gray sunken central area. Coalescence of large lesions gave rise to extensive rotting and necrosis, and the stems were broken when the lesions encircled. Acervuli with brown setae and falcate single-celled spores, typical of some Colletotrichum species (2), formed on the lesions at this late stage. One fungal isolate (Col-68) was obtained from symptomatic tissues on potato dextrose agar that led to white-to-gray appressed mycelium growth with orange conidial masses at 28°C in darkness. Setae were septate, dark brown, rounded and sometimes lobed at base, 32.0 to 116.5 × 3.2 to 6.0 μm, with apices acute. Hyphae were septate, hyaline, 1.0 to 6.5 μm, and sometimes guttulate. Conidia were falcate or fusiform, apices acute or obtuse, and 8.16 to 26.37 × 2.9 to 9.2 μm with an average of 18.15 × 5.65 μm. Hyphopodial appressoria were smooth, globose to prolate, ovoid or obovoid with obtuse or cylindrical apices, edges entire, and 4.17 to 14.25 × 3.77 to 8.94 μm with an average of 7.0 × 6.9 μm. The pathogen was initially identified as a Colletotrichum species based on morphology. Suspensions of 3-day-old spores collected from potato dextrose liquid cultures (10⁶ conidia per ml) were used to spray inoculate (15 ml per pot) three 9-cm-diameter pots of crabgrass seedlings at the three- to four-leaf growth stage. Another three pots of healthy crabgrass were simultaneously sprayed with sterilized distilled water without conidia, which served as noninoculated checks. The seedlings were kept at 25 to 28°C for 24 h under a polyethylene sheet cover in the greenhouse. Symptoms that developed in all inoculated seedlings were identical to those observed on the affected crabgrass in the field, meanwhile the seedlings inoculated with sterilized water had no significant symptoms, and the reisolated strain had the same characteristics as the original isolate. To diagnose the pathogen to the species level, three isolates were tested and an approximately 580-bp DNA amplicon of this isolate was amplified using the primers ITS1/ITS4. The sequence (GenBank Accession No. GQ456160) had 98% sequence identity with the sequences of Colletotrichum hanaui (GenBank Accession Nos. EU554101and EU554124), which is supported by phylogenetic analysis with bootstrap support. On the basis of the morphological, pathological characteristics, and phylogenetic tree, the isolated strain was identified as C. hanaui (1). To our knowledge, this is the first confirmed report of anthracnose of D. sanguinalis caused by newly described C. hanaui in China. References: (1) J. A. Crouch et al. Mycologia, 101:717, 2009. (2) B. C. Sutton. The Coelomycetes. CAB International Publishing, New York, 1980. (3) Y. Z. Zhu and S. Qiang. Chin. J. Biol. Control 20:206, 2004.

Administration of donor-derived mesenchymal stem cells can prolong the survival of rat cardiac allograft

BACKGROUND

Mesenchymal stem cells (MSCs) are multipotent adult elements that have recently been shown to have profound immunomodulatory effects both in vitro and in vivo. Herein we have examined the impact of intravenous infusion of donor MSCs on the survival of transplanted hearts in a rat allograft model.

METHODS

Recipient Fisher344 rats were transplanted with hearts from inbred Wistar rats. Wistar rat MSCs were infused via the tail vein at designated intervals. In vitro mixed lymphocyte reaction (MLR) and cell-mediated lympholysis (CML) assays were performed to assess whether MSCs downregulated T-cell responses in vivo. Real-time polymerase chain reaction (PCR) was used to analyze the Th1/Th2 balance in MSC-treated and control groups.

RESULTS

The MSCs cultured in vitro exhibited multipotential for differentiation. Survival of the allografts was markedly prolonged by administration of MSCs compared with the controls, namely mean survivals of 12.4 vs 6.4 days, respectively. Real-time PCR showed a shift in the Th1/Th2 balance toward Th2. By MLR and CML assays, untreated control rats showed greater alloreactivity than did MSC-treated rats.

CONCLUSION

Our results indicated that MSCs suppressed allogeneic T-cell responses both in vitro and in vivo. Intravenous administration of MSCs prolonged the survival of transplanted hearts, possibly by induction of allograft tolerance through changing the Th1/Th2 balance.

Isolation and developmental expression of two nuclear receptors, MHR4 and betaFTZ-F1, in the tobacco hornworm, Manduca sexta

The cDNAs for two members of the nuclear receptor superfamily were isolated from the tobacco hornworm, Manduca sexta. The deduced amino acid sequence of MHR4 shows 93-95% identity in the DNA-binding domain and the first portion of the hinge (D) region with the germ cell nuclear factor (GCNF)-related factors (GRFs) of the silkworm, Bombyx mori, and the mealworm, Tenebrio molitor, and with a genomic sequence from the fruit fly, Drosophila melanogaster. Northern blot hybridization showed that a 7.5 kb MHR4 mRNA appeared in Manduca abdominal epidermis just as the ecdysteroid titer began to decline during the larval molt, disappeared about 12 h later, then transiently reappeared shortly before larval ecdysis. During the pupal and adult molts, a similar pattern of expression was seen (the very end of the adult molt was not studied). At peak times of expression in the epidermis, MHR4 mRNA was also present in fat body and the central nervous system (CNS). The deduced amino acid sequence of Manduca FTZ-F1 is 100% and 96% identical to that of B. mori and Drosophila betaFTZ-F1, respectively, in the DNA-binding domain and the adjacent hinge region including the FTZ-F1 box. Northern blot analysis showed that the >9.5 kb betaFTZ-F1 mRNA appeared in Manduca epidermis during the decline of the ecdysteroid titer in the larval, pupal and adult molts as the first peak of MHR4 mRNA declined, then it disappeared in the larval and pupal molts before the second peak of MHR4 appeared. betaFTZ-F1 mRNA was also found in fat body and the CNS at the time of peak expression in the epidermis during the larval and pupal molts. Both MHR4 and betaFTZ-F1 mRNAs were found in the testis during the onset of spermatogenesis in the prepupal period.

Carbon dioxide laser induced airway fire during larynx surgery: case report

The precision intrinsic hemostatic properties of the laser have led to its wide use in modern clinical medicine especially in microscopic airway surgery. However, the intense heat generated by the high energy density of the surgical laser can convert combustible tubes into veritable torches, cause catastrophic fires, and result in severe injury to the patient. This is of particular importance when high energy is used on the continuous mode or when the endotracheal tube is repeatedly hit by the laser at the same spot. Most reported laser-induced complications result from the laser beam inadvertently falling on the areas that are not intended to be exposed. We report a case of a trans-tracheostomy tube fire occurring during carbon dioxide (CO2) laser surgery. Aluminum-tape wrapping did not prevent this complication. It was found that the ignition of a trans-tracheostomy tube was caused by the laser striking an unprotected portion of the tube during resection of granuloma of the trachea.

Prolonged interference of patent blue on pulse oximetry readings

BACKGROUND

We evaluated the effect of intra-arterial injection of Patent Blue (PB) on pulse oximetry.

METHODS

Ten consecutive female patients who underwent intra-arterial insertion of catheter for chemotherapy were enrolled in this study. All patients received general anesthesia and ECG, pulse oximetry, and direct arterial blood pressure were monitored throughout the perioperative period. Baseline arterial blood saturation (SpO2), haemoglobin concentration (Hgb), estimated arterial saturation (SaO2), arterial oxygen partial pressure (PaO2) were obtained through arterial blood gas analysis, and true arterial saturation (ScoO2) through CO-Oximetry analysis. The subsequent values obtained at various points of time following the intra-arterial administration of PB were compared with the baseline data.

RESULTS

The SpO2 readings taken after intra-arterial injection of PB were significantly lower than the baseline reading. The extent of the reduction of SpO2 readings two hours after the administration of PB was relevant to the total accumulative dosage of PB (rs = -0.846, P < 0.05). However, the reduction of SpO2 bore no significant relation with Hgb concentration or with the ratio of PB dosage to Hgb concentration.

CONCLUSIONS

Intra-arterial administration of PB interferes with pulse oximetry readings and the effect lasts for a variable duration. The extent of desaturation may be related to the total accumulative dosage of intra-arterial PB injected.

Cutaneous blood vessels in scent pigs

The purpose of this study was to systematically provide anatomic data for flap research in plastic surgery on the cutaneous blood vessels. Seven scent pigs used in this study were killed anesthetically, and their carotid vessels were intubated and injected with a black liquid rubber. Twenty-four hours later, the integument of the scent pig was removed, and the perforating points of the cutaneous vessels were recorded. The different-sized pieces of integument became transparent. Part of this transparent skin tissue was cut into cross-sectional strips. There were three types of the cutaneous vascular source, the same as in humans. Six division levels of vessels in the skin were identified, which formed five vascular plexuses and two systems (the perforating vessel system and the cutaneous vessel system). There were two sets of vein systems: the concomitant vein and the oscillating vein; the latter can be divided into regular and irregular types. The structures of the perforating vessel system and the cutaneous vessel system were the morphological basis for choosing flaps. Two anatomic points have been emphasized: the preserved vascular plexus in thin flaps (not the subcutaneous vascular network reported previously) and the dependency of vascular structure on its location. Otherwise, this study has also provided two new kinds of flaps used in experimental study: the arterial loop flap and the intermuscular septal perforator flap. Although there were differences as well as similarities in skin vasculature between humans and the scent pig, the scent pig is still suitable for flap research.

109 cases of blepharoptosis treated by forked frontalis muscle aponeurosis procedure with long term follow-up

109 cases of severe or recurrent blepharoptosis have been treated with the forked frontalis muscle aponeurosis (FFMA) technique since 1989. In comparison with other frontalis muscle flap (FMF) protocols, this technique has three advantages: (i) no skin incision in the lower rim of the eyebrow; (ii) no incision in the frontalis muscle; and (iii) no dissection under the frontalis muscle. The FFMA is formed at the junction of the frontalis and orbicularis muscles. The 9-year follow-up shows that this is a highly effective procedure. The postoperative function of the frontalis muscle is good and the lack of damage has been confirmed by EMG. There are a few complications such as the sluggishness of the upper eyelid on downward gaze and the possibility of asymmetrical brow height in unilateral blepharoptosis. However, this technique may serve as the best choice in the treatment of severe or recurrent blepharoptosis.

Sequences of two cDNAs encoding silkworm homologues of Drosophila melanogaster squid gene

The squid (sqd) gene of Drosophila melanogaster encodes a few isoforms of a heterogeneous nuclear (hn) RNA-binding protein. We isolated two types of cDNAs coding for homologues of the Sqd protein from the silkworm Bombyx mori. The two predicted amino acid (aa) sequences are identical up to aa 280 and then diverge. The silkworm and fruit fly proteins share 80% homology in the RNA-binding motif region. These cDNAs detect 2.0-, 1.8- and 1-kb mRNAs in the middle and posterior silk glands.

Intermittent expression of BmFTZ-F1, a member of the nuclear hormone receptor superfamily during development of the silkworm Bombyx mori

BmFTZ-F1 is a sequence-specific DNA-binding factor in the silkworm Bombyx mori sharing similar biochemical characteristics with Drosophila FTZ-F1, a member of the nuclear hormone receptor superfamily. Using DNA sequence homology with FTZ-F1 and information on tryptic peptide sequences of BmFTZ-F1, we isolated a cDNA encoding for BmFTZ-F1. Amino acid sequences in the zinc finger DNA-binding region and the putative ligand-binding domain of BmFTZ-F1 showed strong similarity to not only FTZ-F1 but also its mammalian homologues, LRH-1, ELP, and Ad4BP, suggesting the importance of each region for the function of these proteins. Northern blot analyses of RNA isolated from the middle and posterior silk glands and fat bodies showed that a 6.1-kb BmFTZ-F1 mRNA is present in all tissues so far examined. Expression of BmFTZ-F1 mRNA is intermittent, being high during larval molting and both the larval-pupal and the pupal-adult transformations. Injection of 20-hydroxyecdysone at the third day of the 5th instar larvae induced BmFTZ-F1 mRNA in the posterior silk gland after 24 hr. When 5th instar silk glands were cultured in vitro, BmFTZ-F1 mRNA was induced by a 6-hr exposure to 20-hydroxyecdysone followed by 6 hr in hormone-free medium. These results suggest that BmFTZ-F1 is inducible by decline in the ecdysteroid titer and may play an important role in the development of the silkworm as a transcription factor.

A novel DNA-binding motif abuts the zinc finger domain of insect nuclear hormone receptor FTZ-F1 and mouse embryonal long terminal repeat-binding protein

Fruit fly FTZ-F1, silkworm BmFTZ-F1, and mouse embryonal long terminal repeat-binding protein are members of the nuclear hormone receptor superfamily, which recognizes the same sequence, 5'-PyCAAGGPyCPu-3'. Among these proteins, a 30-amino-acid basic region abutting the C-terminal end of the zinc finger motif, designated the FTZ-F1 box, is conserved. Gel mobility shift competition by various mutant peptides of the DNA-binding region revealed that the FTZ-F1 box as well as the zinc finger motif is involved in the high-affinity binding of FTZ-F1 to its target site. Using a gel mobility shift matrix competition assay, we demonstrated that the FTZ-F1 box governs the recognition of the first three bases, while the zinc finger region recognizes the remaining part of the binding sequence. We also showed that the DNA-binding region of FTZ-F1 recognizes and binds to DNA as a monomer. Occurrence of the FTZ-F1 box sequence in other members of the nuclear hormone receptor superfamily raises the possibility that these receptors constitute a unique subfamily which binds to DNA as a monomer.

Reconstruction of the external genitals and repair of skin defects of the perineal region using three types of lateral groin flap

Three types of lateral groin flap have been applied to reconstruct the external genitals and to repair skin defects in the perineal region. A single lateral groin flap was used to construct a vagina for 2 patients who had congenital absence of vagina. A composite flap containing iliac crest bone was applied to reconstruct the penis in 11 patients: 8 suffered traumatic amputation and 3 had congenital micropenis. A coaxial pedicle flap of the lateral groin and abdominal area was used to repair skin defects of the penis and scrotum after resection of the elephantiasis caused by recurrent erysipelas in 2 patients, and to relieve postburn scar contracture in the perineal region in another. Using this operative technique, 14 flaps survived completely with satisfactory results; 70% of one composite flap was lost as a result of hematoma. In the single-flap group, the distal portion (3 x 5 cm) of one flap necrosed and was resected and resurfaced with a free skin graft; the final result was good.

[Application of a lateral groin flap in reconstructive and reparative surgery of the perineal region]

Since March 1983, the authors have applied three types of lateral groin flap to reconstruct the external genitals and to repair skin defects in the perineal region in 16 cases. (1) A single lateral groin flap was used to construct vagina in two patients; (2) A composite flap containing iliac crest bone was applied to reconstruct penis in 11 cases; (3) A coaxial pedicle flap of the lateral groin and lower abdominal area was used to repair skin defects of the penis and scrotum in two cases, and to relieve postburn scar contracture in the perineal region in another. 14 flaps survive completely with satisfactory results. 70 per cent of 1 composite flap was lost because of hematoma. The distal portion (3 x 5 cm) of 1 single flap necrosed due to injury of the deep branch of SCIA during operation and resurfaced with a free skin graft, final result is fair.

The vascular microanatomy of skin territory of posterior forearm and its clinical application

We have undertaken a microanatomical study of a new donor site--the posterior forearm territory--on 43 cadaver arms. Two axial arteries were found, and both the fasciocutaneous flap and the fascial flap could be elevated with the two arteries on the posterior forearm. The posterior forearm flap was transferred to the hand to repair deformities of the wrist, the first web space, the dorsal hand, and the metacarpophalangeal joints in eight cases. The result was very satisfactory. The posterior forearm flap is near the hand, easy to perform, and reliable. It is a one-stage operation and does not sacrifice a main artery. In this article we demonstrate our own ideas about flap extension, which is valuable for clinical application.

One-stage reconstruction of the penis with composite iliac crest and lateral groin skin flap

We present a new method for a one-stage phalloplasty. In forming the penile body and its rigid supporting tissue, a composite flap, including the lateral groin skin flap (11 cm long and 10 cm wide) and the iliac crest bone in its entire length, is designed based on the superficial circumflex iliac artery and its accompanying veins. The urethra is constructed by one of two types of skin flap. When the skin of the scrotal septal area is good and hairless and the urethral opening is located at the pubic symphysis, a scrotal septal skin flap is used. When the scrotal skin cannot be used and the urethral opening is located in the scrotum or perineum, a superficial inferior epigastric vessel island skin flap can be selected. Since April 1983, the method has been used to reconstruct the penis in 4 patients. All operations were successful. The technique is described in detail and the advantages and disadvantages are stated.