Millesi, Elena

Background: The sural nerve is widely used as a nerve graft for various types of peripheral nerve repair due to its ease of harvest and acceptable donor-site morbidity. Nevertheless, certain clinical scenarios, such as cable grafting or multiple cross-face nerve grafts, require grafts longer than the typical 35 cm. This study aims to investigate the anatomic feasibility and clinical safety of an extended sural nerve harvest above the popliteal crease by interfascicular dissection. Methods: An anatomic study using 5 fresh-frozen cadaver legs was conducted, focusing on identifying the anatomic relationship of the sural nerve above the popliteal crease to its surrounding structures and nerve histopathology. A retrospective review was performed of all patients who underwent an extended sural nerve harvest, and patient outcomes, including nerve graft length and postoperative complications, were reviewed to evaluate the clinical feasibility of the extended harvest technique. Results: Anatomic dissection revealed that interfascicular dissection allowed for an additional 14.3 ± 6 cm of nerve length, achieving a total graft length of 49.1 ± 5 cm. Histologic analysis showed no significant differences in fascicle number or axon count along the nerve. A retrospective review, which included 7 adults and 2 pediatric patients, demonstrated that an extended sural nerve harvest was feasible and safe. The maximum graft length was 55 cm, and no intraoperative complications or functional deficits were reported. Conclusion: The extended sural nerve harvest above the popliteal crease with a step-incision approach was both anatomically feasible and clinically safe, providing additional graft length without increasing donor-site morbidity.

Background Facial synkinesis is characterized by involuntary co-contraction of facial muscles during voluntary movements, impairing both function and aesthetics following facial paralysis. It affects approximately 21% of individuals following Bell's palsy, with symptoms such as involuntary eye closure when smiling. While the pathophysiology remains unclear, therapeutic options range from conservative approaches like botulinum toxin to surgical interventions. A bibliometric analysis offers insights into research trends, key contributors, and knowledge gaps in this field. Materials & Methods A systematic search was conducted in the Scopus database up to July 2024, identifying 100 most-cited articles on facial synkinesis. Articles were categorized as basic science (BSc), clinical (CL), or review articles, with additional data extracted on study focus, journal type, citation metrics, and authorship. Statistical analyses included Pearson's χ2 and Wilcoxon rank sum tests. Results The articles spanned 1952–2020, with the highest publication frequency in 2017. Clinical studies constituted 76%, focusing on conservative treatments (35%), diagnostics (28%), and surgical interventions (19%). Plastic surgery and ENT journals accounted for 76% of publications. The most-cited article, published in neurology (1975), investigated electrophysiologic diagnostics. Citation metrics revealed a mean citation count of 38.3 and a median publication year of 2010. The 50 newer articles demonstrated a trend toward surgical management of synkinesis. Conclusions This bibliometric analysis highlights the evolution of research on facial synkinesis, emphasizing the predominance of clinical studies, focus on conservative treatments and gaps in basic science research. Further research is needed to fill knowledge gaps to improve outcomes for affected patients.

Summary: Breast cancer is a common malignancy, and treatment often involves mastectomy. For oncological safety, the anterior and lateral cutaneous branches of the third through fifth intercostal nerves are routinely resected during nipple-sparing mastectomies, leading to loss of nipple sensation. The current gold standard for nipple neurotization uses nerve allografts to connect the nipple with a remaining stump of an intercostal nerve. Despite the convenience of off-the-shelf solutions, this study explored a novel approach using intercostal nerves as autografts or for direct repair to restore nipple sensation. Six patients underwent nipple-sparing mastectomy and opted for nipple neurotization. Three patients underwent neurotization with an intercostal nerve autograft, whereas in 3 patients, long intercostal nerves allowed nipple neurotization directly without the need for an autograft. Meticulous dissection of the intercostal nerves enabled a length of approximately 9 cm (±1.5) per nerve. The acquired nerve length allowed tension-free coaptation of direct nipple neurotization in 3 patients and utilization as an autograft in the other 3 patients. No postoperative complications were observed, whereas sensory outcomes are yet to be evaluated. The study highlighted the feasibility of using intercostal nerves either as autologous intercostal nerve grafts or for direct neurotization. Using an intercostal nerve as an autograft is a cost-effective and time-efficient strategy to avoid the need for an allograft without additional donor-site morbidity. This technique offers a practical and globally accessible solution for improving patient access to state-of-the-art postmastectomy breast reconstruction.

Summary: Facial synkinesis manifests as involuntary muscle movements alongside volitional facial actions and is typically managed with a combination of neuromuscular retraining, botulinum toxin injections, and in some cases, selective neurectomy. Some patients with synkinesis describe persistent neck tightness or pain at the level of the mandibular angle and horizontally towards the midline, similar to the anatomic course of the posterior belly of digastric (PBD) and stylohyoid muscles. There are limited studies exploring the involvement of the PBD and stylohyoid muscles in facial synkinesis and the use of chemodenervation as treatment. Herein, we present 2 patients with facial synkinesis and ipsilateral neck tightness and pain who underwent novel surgical treatment in the form of the standard selective neurectomy procedure along with a myectomy of the PBD and stylohyoid muscles. Following completion of the standard steps of selective neurectomy, the PBD and stylohyoid muscles were carefully dissected and separated from the surrounding structures. Both muscles were divided using bipolar electrocautery. Both patients reported improvement of neck pain and tightness immediately after the intervention and at the 6.5-month follow-up visit. These preliminary results show promise in aiding a subset of patients with synkinesis-related neck pain and tightness.

Aging disrupts multiple homeostatic processes, including autophagy, a cellular process for the recycling and degradation of defective cytoplasmic structures. Acute treatment with the autophagy inhibitor chloroquine blunts the maximal forces generated by the diaphragm muscle, but the mechanisms underlying neuromuscular dysfunction in old age remain poorly understood. We hypothesized that chloroquine treatment increases the presynaptic retention of the styryl dye FM 4-64 following high-frequency nerve stimulation, consistent with the accumulation of unprocessed bulk endosomes. Diaphragm-phrenic nerve preparations from 24-month-old male and female C57BL/6 × 129 J mice were incubated with FM 4-64 (5 µM) and either chloroquine (50 µM) or vehicle during 80 Hz phrenic nerve stimulation. Acute chloroquine treatment significantly decreased FM 4-64 intensity at diaphragm neuromuscular junctions following 80 Hz phrenic nerve stimulation, consistent with disrupted synaptic vesicle recycling. A similar reduction was evident in regions with the greatest FM 4-64 fluorescence intensity, which most likely surround synaptic vesicle release sites. In the absence of nerve stimulation, chloroquine treatment significantly increased FM 4-64 intensity at diaphragm neuromuscular junctions. These findings highlight the importance of autophagy in regulating presynaptic vesicle retrieval (including vesicle recycling and endosomal processing) and support the role of autophagy impairments in age-related neuromuscular dysfunction.

Abstract Giant intracranial aneurysms require complex treatment strategies including clipping, coiling, stenting, parent artery occlusion, bypass, or combined procedures. Neurovascular hybrid operating rooms (h-OR) combine a conventional operating theatre with high-resolution digital subtraction angiography (DSA). We describe a one-step combined surgical and endovascular treatment in a h-OR for a pediatric internal carotid artery (ICA) giant aneurysm that can be an optimal solution to manage such challenging cases. An 11-year-old boy presented with rapid onset right hemiparesis and left eyelid ptosis. A 3-month history of headache associated with sporadic vomit was reported. A giant, unruptured, left ICA aneurysm was detected on imaging. The patient underwent surgical trapping of the aneurysm. Intraoperative DSA showed residual backflow from the posterior communicating artery and coils were placed to completely exclude the aneurysm. At 18-month follow-up, the patient showed a complete recovery and magnetic resonance imaging showed a progressive reduction of the sac aneurysm. Due to their morphological variability, intracranial giant aneurysms may require a different procedural strategy instead of direct clipping or coiling. The introduction of h-OR allows combined treatments to be performed simultaneously in the same room setting. The present case shows that combined treatment in a neurovascular h-OR can be an optimal solution to manage challenging cases, such as giant aneurysms, reducing operative time with the added benefit of selecting an appropriate strategy adjustment in a multidisciplinary effort.

Background: In 2020, the American Board of Plastic Surgeons announced an update in the leave policy for plastic surgery trainees, extending personal leave to 12 weeks without delay in graduation. Simultaneously, the Accreditation Council for Graduate Medical Education announced their update in lactation policy. This study sought to understand the influence of the policy change on plastic surgery trainees’ goals for family planning and lactation. Methods: An online 32-question survey was developed to evaluate plastic surgery trainees’ perceptions of family planning and perceived program support in the United States. The survey was approved by the American Council of Academic Plastic Surgeons Research Committee and sent out to a total of 216 plastic surgery programs. Results: One hundred thirty plastic surgery trainees completed the survey. Most respondents were women, between the ages of 30 and 34 years, and married. Forty-five (34.6%) respondents or their partners had experienced pregnancy or live birth during their training. More than 70% did not feel that they had adequate time for leave. Female trainees faced more barriers than men, including having a partner in training, concern for their pregnancy, and burdening their co-residents during leave. The majority stated that their decision to apply to plastic surgery residency was influenced by program support for family planning compared with policy changes. Conclusions: This survey highlighted that the new policies benefit trainees who consider starting a family during training. Despite this, there are still challenges that need to be addressed to help foster a fair environment for trainees to work and have a family.