Midcheek mass: 10 year of clinical experience

This is a literature review and retrospective chart review of ten years experience on the treatment of midcheek masses in our department. The purpose of this study is to provide the reader with an overview of the pathology of this complex anatomic area focusing the attention on the differential diagnosis and the recent surgical strategies.From May 2002 to December 2012 we enrolled 22 consecutive patients studied for masses located in the midcheek area. Only four studies were found in the literature describing the experience of individual centres reporting few cases of midcheek masses. Combined with the previously reported 37 cases, we describe 22 lesions for a total of 59 cases. Patients were evaluated with a head and neck clinical and instrumental examination. Apart from 4 cases treated with intramuscular infiltration of botulinum toxin for masseter hypertrophy, surgical approach to the lesions was varied: 10 patients received an external approach (standard parotidectomy approach or face-lift-type approach); 6 patients had the lesion removed through an intraoral approach; in 2 cases a direct skin incision was performed. In our series we found a significant rate (55.5%) of temporary complications in all the procedures performed (external, intraoral, direct skin approach). This study aims to emphasize the role of endoscope assisted surgery as a possible alternative to the traditional approaches for the management of well selected benign midcheek masses.It would be advisable to increase the study of the endoscopic anatomy of the midcheek area in order to standardize the procedure and better define the surgical indications.     

Purine Metabolism During Microsurgical Transfer of Human Skeletal Muscle

The effect of ischaemia followed by reperfusion on energy metabolism was studied in human skeletal muscle after microsurgical free transfer. Muscle biopsy specimen from 11 patients treated by free muscle transfer for facial palsy, injury to an extremity, or scalp defect were studied. The biopsy specimens were taken during ischaemia and after one hour of reperfusion, respectively. They were analysed for ATP to uric acid and creatine phosphate by high pressure liquid chromatography. Ischaemia lasting one or two hours affected the energy metabolism of the muscle cell as evidenced by a 50% reduction in creatine phosphate; a 20% reduction in ATP and in the energy charge; a 100% increase in inosine monophosphate, and a 700% increase in hypoxanthine and xanthine. Reperfusion for one hour improved these figures somewhat, and induced the production of uric acid. Skeletal muscle can therefore tolerate ischaemia for up to two hours in the clinical situation without permanent damage to the tissues.     

Key changes in denervated muscles and their impact on regeneration and reinnervation

The neuromuscular junction becomes progressively less receptive to regenerating axons if nerve repair is delayed for a long period of time. It is difficult to ascertain the denervated muscle＇s residual receptivity by time alone. Other sensitive markers that closely correlate with the extent of denervation should be found. After a denervated muscle develops a fibrillation potential, muscle fiber conduction velocity, muscle fiber diameter, muscle wet weight, and maximal isometric force all decrease; remodeling increases neuromuscular junction fragmentation and plantar area, and expression of myogenesis-related genes is initially up-regulated and then down-regulated. All these changes correlate with both the time course and degree of denervation. The nature and time course of these denervation changes in muscle are reviewed from the literature to explore their roles in assessing both the degree of detrimental changes and the potential success of a nerve repair. Fibrillation potential amplitude, muscle fiber conduction velocity, muscle fiber diameter, mRNA expression levels of myogenic regulatory factors and nicotinic acetylcholine receptor could all reflect the severity and length of denervation and the receptiveness of denervated muscle to regenerating axons, which could possibly offer an important clue for surgical choices and predict the outcomes of delayed nerve repair.     

Obesity and Physical Frailty in Older Adults: A Scoping Review of Lifestyle Intervention Trials

Many frail older adults are thin, weak, and undernourished; this component of frailty remains a critical concern in the geriatric field. However, there is also strong evidence that excessive adiposity contributes to frailty by reducing the ability of older adults to perform physical activities and increasing metabolic instability. Our scoping review explores the impact of being obese on physical frailty in older adults by summarizing the state of the science for both clinical markers of physical function and biomarkers for potential underlying causes of obesity-related decline. We used the 5-stage methodological framework of Arksey and O'Malley to conduct a scoping review of randomized trials of weight loss and/or exercise interventions for obesity (body mass index ≥ 30 kg/m²) in older adults (aged >60 years), examining the outcomes of inflammation, oxidative stress, and lipid accumulation in muscle, as well as direct measures of physical function. Our initial search yielded 212 articles; exclusion of cross-sectional and observational studies, cell culture and animal studies, disease-specific interventions, and articles published before 2001 led to a final result of 21 articles. Findings of these trials included the following major points. The literature consistently confirmed benefits of lifestyle interventions to physical function assessed at the clinical level. Generally speaking, weight loss alone produced a greater effect than exercise alone, and the best outcomes were achieved with a combination of weight loss and exercise, especially exercise programs that combined aerobic, resistance, and flexibility training. Weight loss interventions tended to reduce markers of inflammation and/or oxidative damage when more robust weight reduction was achieved and maintained over time, whereas exercise did not change markers of inflammation. However, participation in a chronic exercise program did reduce the oxidative stress induced by an acute bout of exercise. Weight loss interventions consistently reduced lipid accumulation in the muscle; however, in response to exercise, 3 studies showed an increase and 2 a decrease in muscle lipid infiltration. In summary, this scoping review identified strong clinical evidence that weight reduction and/or exercise interventions can improve physical function and biomarkers of physical dysfunction among overweight/obese older adults, supporting the suggestion that excessive adiposity contributes to physical frailty. However, the evidence also suggests a complexity of metabolic influences, both systemically and within muscle, which has not been elucidated to date. Considerable further study is needed to examine the mechanisms by which lifestyle interventions influence physical frailty before the net impact of such interventions can be fully understood.     

重症肢体缺血的中西医治疗进展

慢性下肢动脉硬化闭塞症引起的重症下肢缺血是血管外科治疗的难题,临床治疗包括药物治疗、外科手术、腔内手术、腔内手术和介入手术结合的杂交手术、干细胞移植及中医中药治疗,以上各方面治疗均取得可喜的成绩,现综述如下。     

Indices of Obesity and Behaviour of the Pedicled Tram Flap in Breast Reconstruction

The association between obesity and the outcome of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps was studied in 12 patients. Obesity was assessed preoperatively by body mass index (BMI) and waistship circumference ratio (WHCR). The thickness of the abdominal fat and muscles was measured preoperatively with ultrasonography on the abdomen and during the nine postoperative months on the flap. Marginal or fat necrosis was more common among patients with lower body type fat distribution (WHCR less than 0.80) than in patients with medium or upper body type fat distribution. BMI and abdominal muscle and fat thicknesses were not associated with marginal or fat necrosis of the flaps. We conclude that lower body (female type) fat distribution may be associated with marginal cutaneous or fat necrosis in pedicled TRAM flaps.