Breast reconstruction is a cosmetically critical procedure for women and it must be undertaken to balance the shape, size, and position of the breast with the other breast. Since the first introduction of the free abdominoplasty flap in 1979, the transverse rectus abdominis musculocutaneous (TRAM) flap technique has been a widely accepted method of breast reconstruction after mastectomy. In breast reconstruction with a free flap, the selection of suitable recipient vessels is the critical decision to be made by the surgeon. The most common recipient vessel for free flap breast reconstruction is the axillary system. However, when used as a recipient, the axillary system may limit flap movement and flexibility in breast shaping. The use of the internal mammary vessels as a recipient site attains ideal breast symmetry. However, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft, which requires the internal mammary artery. Based on these considerations, the selection of suitable recipient vessels constitutes an important requirement for successful free tissue transfer. The authors have performed breast reconstruction with the TRAM flap anastomosed to the internal mammary perforator vessel and conclude that these perforators could be useful as recipient vessels, especially in the case of immediate breast reconstruction with the free TRAM flap.

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PurposeWe present our experience involving the management of this disease, identifying prognostic factors affecting treatment outcomes.MethodsThe patients treated for Fournier gangrene at our institution were retrospectively reviewed. Data collected included demographics, extent of soft tissue necrosis, predisposing factors, etiological factors, laboratory values, and treatment outcomes. The severity index and score were calculated. Multivariate regression analysis was used to determine the association between potential predictors and clinical outcomes.ResultsA total of 41 patients (male:female = 33:8) were studied. The mean age was 54.4 years (range, 24–79 years). The most common predisposing factor was diabetes mellitus (n = 19, 46.3%). Sixteen patients (39.0%) were current smokers. Seven patients had chronic kidney disease. The most frequent etiology was urogenital lesion (41.5%). The mortality rate was 22.0% (n = 9). Multivariate regression analyses showed that extension of necrosis beyond perineal/inguinal area and pre-existing chronic kidney disease were significant and independent predictors of mortality. Extension of necrosis beyond perineal/inguinal area was a significant predictor of increased duration in the intensive care unit and hospital stay. In addition, pre-existing chronic kidney disease was a significant predictor of flap reconstruction in the wound.ConclusionFournier gangrene with extensive soft tissue necrosis and pre-existing chronic kidney disease was associated with poor prognosis and complexity of patient management. Early recognition of dissemination and premorbid renal function is essential to reduce mortality and establish a management plan for this disease.

Non-melanoma skin cancers (NMSC) including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are more common kinds of skin cancer. Although these tumors share common pathological and clinical features, their similarity and heterogeneity at molecular levels are not fully elaborated yet. Here, by performing comparative analysis of gene expression profiling of BCC, SCC, and normal skin tissues, we could classify the BCC into three subtypes of classical, SCC-like, and normal-like BCCs. Functional enrichment and pathway analyses revealed the molecular characteristics of each subtype. The classical BCC showed the enriched expression and transcription signature with the activation of Wnt and Hedgehog signaling pathways, which were well known key features of BCC. By contrast, the SCC-like BCC was enriched with immune-response genes and oxidative stress-related genes. Network analysis revealed the PLAU/PLAUR as a key regulator of SCC-like BCC. The normal-like BCC showed prominent activation of metabolic processes particularly the fatty acid metabolism. The existence of these molecular subtypes could be validated in an independent dataset, which demonstrated the three subgroups of BCC with distinct functional enrichment. In conclusion, we suggest a novel molecular classification of BCC providing insights on the heterogeneous progression of BCC.

A bnormal posture of the head and neck can happen to anybody from neonates to adults, which requires appropriate interventions according to etiologies. Congenital muscular torticollis is the most common cause of abnormal posture of the head and neck in infancy, where early intervention as soon as possible is critical for better therapeutic outcome. Childhood laterocollis is heterogeneous condition, which needs etiological diagnosis for the proper management. Cervical dystonia is the most common form of focal dystonia and an overview on clinical presentations and therapeutic options including chemodenervation with botulinum toxin injection was provided. Abnormal posture of the head and neck of acute onset could be a sign of serious conditions and needs differential diagnosis.