Grace Lee Peng

BMI-1 Promotes Ewing Sarcoma Tumorigenicity Independent of CDKN2A Repression

Deregulation of the polycomb group gene BMI-1 is implicated in the pathogenesis of many human cancers. In this study, we have investigated if the Ewing sarcoma family of tumors (ESFT) expresses BMI-1 and whether it functions as an oncogene in this highly aggressive group of bone and soft tissue tumors. Our data show that BMI-1 is highly expressed by ESFT cells and that, although it does not significantly affect proliferation or survival, BMI-1 actively promotes anchorage-independent growth in vitro and tumorigenicity in vivo. Moreover, we find that BMI-1 promotes the tumorigenicity of both p16 wild-type and p16-null cell lines, demonstrating that the mechanism of BMI-1 oncogenic function in ESFT is, at least in part, independent of CDKN2A repression. Expression profiling studies of ESFT cells following BMI-1 knockdown reveal that BMI-1 regulates the expression of hundreds of downstream target genes including, in particular, genes involved in both differentiation and development as well as cell-cell and cell-matrix adhesion. Gain and loss of function assays confirm that BMI-1 represses the expression of the adhesion-associated basement membrane protein nidogen 1. In addition, although BMI-1 promotes ESFT adhesion, nidogen 1 inhibits cellular adhesion in vitro. Together, these data support a pivotal role for BMI-1 ESFT pathogenesis and suggest that its oncogenic function in these tumors is in part mediated through modulation of adhesion pathways.

The Supraclavicular Artery Island Flap in Head and Neck Reconstruction: Applications and Limitations

IMPORTANCE The supraclavicular artery island (SAI) rotational flap may have advantages compared with free-tissue transfer in head and neck reconstruction. Because this flap has not been extensively described for head and neck reconstruction of oncologic defects, guidelines for its indications would benefit the reconstructive surgeon. OBJECTIVE To describe the applications and limitations of the SAI flap as an alternative to free-tissue transfer in reconstruction of head and neck defects. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 45 patients with defects related to malignant and nonmalignant disease undergoing reconstructive surgery from August 18, 2010, through September 28, 2012, at an academic, tertiary referral center. Each defect was deemed unsuitable for primary or local flap closure and would require regional tissue or free-tissue transfer. Mean follow-up was 10.3 (range, 1-31) months. INTERVENTION Use of the SAI flap for reconstruction of soft-tissue defects of the head and neck. MAIN OUTCOMES AND MEASURES Defect site, flap dimensions, time to raise the flap, and complications. RESULTS Defects of the oral cavity, oropharynx, laryngopharynx, esophagus, trachea, temporal bone, and cervicofacial skin underwent reconstruction. Mean flap dimensions were 6.1 cm wide and 21.4 cm long, with a mean skin paddle length of 7.9 cm. Harvest time was less than 1 hour. Donor-site complications included minor dehiscence in 6 patients and prolonged wound care in 2. Partial skin flap necrosis occurred in 8 patients, whereas 2 had complete loss of the skin paddle. Seven patients developed a salivary fistula, 4 of which healed spontaneously. Flap length greater than 22 cm correlated with flap necrosis (P = .02). A history positive for smoking correlated with an increased risk of flap dehiscence (P = .02). CONCLUSIONS AND RELEVANCE The SAI flap provides an alternative to free-tissue transfer for soft-tissue reconstruction after head and neck oncologic surgery. This flap is easy to harvest and versatile. However, the SAI flap has limitations in length and, because it is a rotational flap, is less capable of reconstructing some complex head and neck defects.

Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of transposing fat to the subperiosteal vs supraperiosteal planes.

IMPORTANCE Differences in technique and outcome between fat transposed to the subperiosteal and supraperiosteal planes during transconjunctival lower blepharoplasty remain to be elucidated. OBJECTIVE To provide a single-surgeon comparison of transconjunctival lower blepharoplasty with fat repositioning (TCBFR) to the subperiosteal vs the supraperiosteal plane. DESIGN A retrospective medical record review of patients who underwent TCBFR to the subperiosteal or the supraperiosteal plane by a single surgeon from January 1, 2009, through December 31, 2011. Differences in surgical technique, postoperative course, complications, patient satisfaction, and aesthetic results (by blinded assessment of preoperative and postoperative photographs) are reviewed using a 4-point scale. SETTING An ophthalmic plastic surgical practice. PARTICIPANTS The first 20 consecutive patients who underwent TCBFR to the supraperiosteal plane and the previous 20 who underwent TCBFR to the subperiosteal plane. INTERVENTION Transconjunctival lower blepharoplasty with fat repositioning. MAIN OUTCOME MEASURES Intraoperative findings, postoperative course, complications, and aesthetic results. RESULTS We included 40 patients (27 women and 13 men) with a mean age of 57 years and mean follow-up of 10 months. Subperiosteal TCBFR was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal surgery was faster yet more traumatic, leading to more bruising, swelling, and with more clinically evident temporary postoperative contour irregularities. All patients expressed a high level of satisfaction (100%). Blinded assessment of results demonstrated no statistically significant difference (P = .45) between the 2 surgical approaches with regard to the final aesthetic result. CONCLUSIONS AND RELEVANCE Transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results are comparable between the 2 approaches. LEVEL OF EVIDENCE 4.

Use of the Supraclavicular Artery Island Flap for Reconstruction of Cervicofacial Defects

Objective To describe the supraclavicular artery island (SAI) flap as an alternative flap for reconstruction of cervicofacial defects. Study Design Case series with chart review. Setting Academic, tertiary referral center. Subjects and Methods Twenty-two patients with defects of the face, temporal bone, and neck were reconstructed with an SAI flap. Each defect was deemed unsuitable for primary or local flap closure and would require regional or free tissue transfer. Outcome measures included size and location of the defect, time to raise the flap, flap size and viability, and complications. Mean follow-up was 7.4 months (range, 1-31 months). Statistical analysis was performed using SAS 9.1 (SAS Institute, Cary, North Carolina). Results Defects of the cervical skin (n = 10), face (n = 8), and temporal bone (n = 4) were reconstructed. Mean flap dimensions were 6.1 cm (range, 5-7 cm) wide and 21.8 cm (range, 16-28 cm) long. The proximal portion of the flap was deepithelialized to match the defect, resulting in a mean skin paddle length of 9.6 cm (range, 5-18 cm). Minor donor site dehiscence occurred in 3 patients. Partial skin flap necrosis occurred in 2 patients, while 1 patient had complete loss of the skin paddle. There was no statistical correlation between flap necrosis and flap length (P = .3, χ2) or defect location (P = .13, χ2). Conclusion The SAI flap is a viable alternative to cervicofacial advancement or microvascular reconstruction of cervicofacial defects in select cases. This flap is reliable, easy to harvest, and versatile, and it provides a good color match for cervicofacial defects.

Effacing the Orbitoglabellar Groove With Transposed Upper Eyelid Fat

Purpose: An age-related depression can develop over the superonasal orbital rim, which the authors have called the “orbitoglabellar groove (OGG).” It is, in part, related to volume loss over the rim as is seen at the lower eyelid/cheek interface (nasojugal groove). An upper eyelid fat pedicle can be transposed over the OGG during standard upper blepharoplasty surgery to reduce this depression. Methods: The charts of patients who underwent fat transposition to the OGG during upper blepharoplasty over a 20-month period (2010–2012) are retrospectively reviewed. Only primary eyelid surgery patients are included in the study. The procedure, its results, and complications are presented. Results: Seventeen patients are included in this study. Eleven patients (65%) are women and 6 (35%) patients are men. The average patient age is 56 years (range 47–80 years), and the average follow up is 10 months (6–14 months). Two patients (12%) developed a transient induration over the transposed fat pedicle in the postoperative period which resolved with a combination 5-fluorouracil/kenalog injection. There were no cases of postoperative infection, prolonged swelling, motility disturbance, diplopia, or eyelid malposition. Clinical effacement of the OGG was noted in all cases, and physician and patient assessment of surgical results are equally good. Conclusions: The OGG is an involutional periorbital hollow present over the superonasal orbital rim. The depression can be reduced with native eyelid fat transposition during upper blepharoplasty in a similar way that lower blepharoplasty with fat repositioning effaces the nasojugal groove. The learning curve for the procedure is quick, especially for those who have experience with its lower eyelid counterpart.

Microbiology and Antibiotic Prophylaxis in Rhinoplasty: A Review of 363 Consecutive Cases

IMPORTANCE A practical technique for reducing infectious complications from rhinoplasty would represent an important surgical advance. OBJECTIVES To describe the microbial flora of patients undergoing septorhinoplasty and to evaluate the role of preoperative and postoperative antibiotic prophylaxis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective medical record review of 363 consecutive adult patients who underwent preoperative nasal swab testing and rhinoplasty or septorhinoplasty in a single private practice: 279 women (76.9%) and 84 men (23.1%). The average patient age was 35.9 years (age range, 17-70 years). MAIN OUTCOMES AND MEASURES Identification of endogenous nasal flora and pathogenic bacteria treated with culture-directed antibiotics; evaluation of comorbidities, perioperative infections, and antibiotic treatments. RESULTS A total of 174 patients (47.9%) underwent primary rhinoplasty, and 189 (52%) underwent revision rhinoplasty. On preoperative nasal culture, 78.2% of patients had normal flora; 10.7% had Staphylococcus aureus; and 0.28% had methicillin-resistant S aureus (MRSA). In 7.4% of patients, fecal coliforms including Escherichia coli, Enterobacter species, and Citrobacter species were found. Age, sex, smoking, the use of oral contraceptives, or the presence of seasonal allergies did not significantly change the nasal flora or the postoperative infection rate. Patients with adult acne were found to have an increased incidence of colonization with fecal coliforms (43.8%; P < .001). Patients with diabetes were found to have an increased incidence of colonization with S aureus (66.7%; P = .002). The overall infection rate was 3.0% (11 of 363 patients), with 4.0% (7 of 174 patients) seen in primary septorhinoplasties and 2.1% (4 of 189 patients) seen in revision cases. Coliforms accounted for 5 cases (45.5%) of postoperative infections, while S aureus was responsible for 4 cases (36.4%), including 1 case of MRSA. CONCLUSIONS AND RELEVANCE The results of this study suggest that risk factors alone may not reliably predict the subset of patients in whom antibiotic prophylaxis is indicated. Knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help to further reduce the incidence of infectious complications. LEVEL OF EVIDENCE 3.

Cross-Facial Nerve Grafting for Facial Reanimation

Dynamic facial reanimation is the gold standard treatment for a paralyzed face. Over the last century, multiple nerves have been utilized for grafting to the facial nerve in an attempt to produce improved movement. However, in recent years, the use of cross facial nerve grafting with a second stage gracilis free flap has gained popularity due to the ability to generate a spontaneous smile and facial movement. Preoperative history taking and careful examination, as well as pre-surgical planning, are imperative to whether cross facial nerve grafting with a second stage gracilis free flap is appropriate for the patient. A sural nerve graft is ideal given the accessibility of the nerve, the length, as well as the reliability and ease of the nerve harvest. The nerve can be harvested using a small incision, which leaves the patient with minimal post operative morbidity. In this chapter, we highlight the pearls and pitfalls of cross facial nerve grafting.

Globe Retropulsion and Eyelid Depression (gred)—a Surgeon-controlled, Unimanual Maneuver to Access Postseptal Fat in Transconjunctival Lower Blepharoplasty

273 To the Editor: Accessing eyelid/orbital fat is a critical step in aesthetic lower blepharoplasty. Historically, fat was identified through an open infracilliary skin incision, which is both quick and direct. While this approach is straightforward and still a contemporary technique today, inherent to it is a skin incision and division of both the orbicularis muscle and orbital septum to enter the fat compartment. This transcutaneous surgical approach has been reported to lead to an increased incidence of postoperative eyelid malposition such as retraction or ectropion. In the 1920s, transconjunctival lower eyelid surgery was described. It fell in disfavor and was rarely employed until the later part of the 20th century when Tomlinson and Hovey and Baylis et al. reintroduced the concept for blepharoplasty surgery. Tomlinson advocated a preseptal dissection with division of the orbital septum to access the fat pads, while Baylis favored a more direct postseptal approach to fat, which leaves the orbital septum undisturbed. Since then, transconjunctival lower blepharoplasty (TCB) has become a common surgical procedure, which has reduced the incidence of lower eyelid malposition after surgery, reported to be as high as 20% with the transcutaneous approach. Traditional techniques in TCB describe creating surgical exposure by inferiorly displacing the lower eyelid with some sort of rake or retractor, while protecting the globe with a corneal shield, Jeager eyelid plate, or similar device. When globe retropulsion is added, eyelid/orbital fat is displaced anteriorly. This simplifies direct entry into the postseptal fat compartment. These manipulations have been described as 2 person dependent (surgeon and assistant) and involve the use of instruments, which cover the eyelid and globe, limiting surgical exposure to only the conjunctiva. In this letter, the “globe retropulsion and eyelid depression (GRED)” maneuver is described. This is an assistant independent manipulation, which involves simultaneous “unimanual” lower eyelid inferior displacement and globe retropulsion (over the closed upper eyelid) with 2 fingers of 1 hand by the surgeon only. The maneuver is quick, simple (with some experience), and reliably promotes direct entry to the clearly delineated postseptal fat compartment without obscuring the globe or lower eyelid from view. This is important because TCB is a more detailed and complex technique than its transcutaneous counterpart, especially when more contemporary adjuncts such as fat transposition are added. As such, surgeons who perform TCB less frequently, have trepidation with manipulations so close to the globe, or are accustomed to, or prefer, the more traditional and direct transcutaneous technique, may avoid this approach. Identifying surgical steps that simplify and add precision to the transconjunctival technique promotes increased confidence and allays fears with the procedure. The GRED maneuver is such a step. The lower eyelid is infiltrated transconjunctivally with 2 ml of 1% xylocaine with 1:100:000 epinephrine. Appropriate time is given for anesthesia and hemostasis to take effect. With the surgeon’s nondominant hand, the lower eyelid is inferiorly displaced with the second finger (third digit), while simultaneously retroplacing the globe with direct gentle pressure with the same hand’s index finger (second digit) or thumb pushing towards the orbital apex (GRED maneuver). The transconjunctival surface of the lower eyelid protrudes forward as eyelid/orbital fat is displaced anteriorly. The tarsus, fused conjunctiva/septum and retractor layer, and yellow fat visible beneath the more inferior posterior eyelid lamella become clearly visible (Fig., top). A perpendicular incision through the conjunctiva/retractors over the fat allows direct entry to the postseptal space and fat prolapses from the surgical wound (Fig., bottom). Fat can then be excised or repositioned as preoperatively planed in the standard way. Simultaneous globe repulsion and inferior lower eyelid displacement improves surgical exposure in TCB because of unique and inerrant anatomical characteristics of the orbit. The orbit is a pear-shaped bony cavity, which houses the globe, extraocular muscles, and fat associated with these structures. As the intraorbital contents are pliable, the orbital walls rigid, and the external diameter of its opening larger than its apical dimensions, anterior–posterior pressure on the globe will force fat anteriorly. When the lower eyelid is inferiorly displaced, the anteriorly repositioned fat “bulges” forward, converting the concave or flat palpebral conjunctival surface into as convex shape with a more visible and clearly delineated anatomy (Fig., top). The yellow fat glistens through the conjunctiva making its exact postseptal location obvious. In the GRED maneuver, simultaneous globe retropulsion and inferior lower eyelid displacement are performed by 1 hand of the surgeon without assistance as 1 brisk manipulation, simplifying postseptal fat access. Also important is that retropulsion is performed with the upper eyelid closed (Fig., bottom) so that the globe gains a layer of protection. Globe Retropulsion and Eyelid Depression (GRED)—A Surgeon-Controlled, Unimanual Maneuver to Access Postseptal Fat in Transconjunctival Lower Blepharoplasty

Neuromuscular electrical stimulation improves radiation-induced fibrosis through Tgf-Β1/MyoD homeostasis in head and neck cancer

The purpose of this study was to analyze TGF‐β1 and MyoD expression in cervical muscles during radiation therapy (RT) and their role in inducing muscle fibrosis in head and neck cancer (HNC) patients. We also studied the effect of combined traditional swallow therapy (TST) and neuromuscular electrical stimulation (NMES) therapy on TGF‐β1/MyoD homeostasis in patients undergoing post‐operative RT for HNC.

Current Trends in Upper and Lower Eyelid Blepharoplasty Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members.

PURPOSE To assess current practice patterns for management of upper and lower eyelid blepharoplasty by active American Society of Ophthalmic Plastic and Reconstructive Surgery members. METHODS An invitation to participate in a web-based anonymous survey was sent to the active American Society of Ophthalmic Plastic and Reconstructive Surgery membership via email. The survey consists of 34 questions, both multiple choice and free response, regarding upper and lower eyelid blepharoplasty surgery. Practice patterns for both aesthetic and functional blepharoplasty are assessed. RESULTS Thirty-four percent (161/472) of American Society of Ophthalmic Plastic and Reconstructive Surgery members polled responded to the survey. Members perform an average of 196 upper eyelid, 46 lower eyelid, and 53 four-eyelid blepharoplasty procedures per year, with 70% of cases being functional and 30% purely aesthetic. Most members prefer monitored care (71%) to local (21%) or general (8%) anesthesia. Eighty-nine percent of surgeons use topical antibiotics after surgery, erythromycin being the most common (51%). Fourteen percent of members use postoperative oral antibiotics, with cephalexin (81%) being most common. In upper eyelid blepharoplasty, orbicularis muscle is excised by 86% of respondents. Orbital fat is excised, when deemed appropriate, in 97% of cases, with nasal fat excised most commonly (88%). Less commonly, fat repositioning (36%) and adjunctive fat grafting (33%) are performed. In lower eyelid blepharoplasty, surgeons report using one or more of the following approaches: transconjunctival (96%), transcutaneous (82%), and both transconjunctival and transcutaneous (51%). Common adjunctive procedures include orbital fat excision (99%), fat repositioning (80%), and lateral canthal suspension (96%). Less common adjunctive procedures include laser skin resurfacing (36%) and chemical peels (29%). CONCLUSIONS This report outlines contemporary practice patterns among active American Society of Ophthalmic Plastic and Reconstructive Surgery members in the management of upper and lower eyelid blepharoplasty. It is important to quantify such data periodically to update the membership as to how this common surgical procedure is approached. This also allows eyelid surgeons to compare their practice patterns with a national group specializing in such surgery.