The mammalian Hox complex is divided into four linkage groups containing 13 sets of paralogous genes. These paralogous genes have retained functional redundancy during evolution. For this reason, loss of only one or two Hox genes within a paralogous group often results in incompletely penetrant phenotypes which are difficult to interpret by molecular analysis. For example, mice individually mutant for Hoxa11 or Hoxd11 show no discernible kidney abnormalities. Hoxa11/Hoxd11 double mutants, however, demonstrate hypoplasia of the kidneys. As described in this study, removal of the last Hox11 paralogous member, Hoxc11, results in the complete loss of metanephric kidney induction. In these triple mutants, the metanephric blastema condenses, and expression of early patterning genes, Pax2 and Wt1, is unperturbed. Eya1 expression is also intact. Six2 expression, however, is absent, as is expression of the inducing growth factor, Gdnf. In the absence of Gdnf, ureteric bud formation is not initiated. Molecular analysis of this phenotype demonstrates that Hox11 control of early metanephric induction is accomplished by the interaction of Hox11 genes with the pax-eya-six regulatory cascade, a pathway that may be used by Hox genes more generally for the induction of multiple structures along the anteroposterior axis.

Background: Liposuction is the treatment of choice for solid predominant extremity lymphedema. The classic lymphedema liposuction technique does not remove skin excess created following bulk removal. The skin excess is presumed to resolve with spontaneous skin contracture. We investigated the technique of simultaneously performing liposuction with immediate skin excision in patients with solid predominant lymphedema and compared the outcome with that from the classic technique. Methods: Modified liposuction with skin excision (mLIPO) and standard liposuction without skin excision (sLIPO) were offered to patients with solid predominant extremity lymphedema. Skin traction of 4 cm and undulating skin mobility constituted positive “flying squirrel” sign. Patients with negative “flying squirrel” sign were excluded. mLIPO patients underwent skin excision. Surgical outcomes and postoperative complications were compared. Results: The study enrolled 15 and 26 patients into the sLIPO and mLIPO groups, respectively. mLIPO patients demonstrated statistically significant decrease in seroma/hematoma, contour irregularity, and skin necrosis, while experiencing increased procedural satisfaction. Conclusions: Skin excision following liposuction for solid predominant lymphedema is safe. It decreases postoperative complication and improves surgical outcome.

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A 73-year old man underwent endovascular aortic aneurysm repair (EVAR) in 2004. Seven years later, he was evaluated by his primary care physician who noticed no recent follow-up examinations by the originally treating vascular surgeon. The patient was subsequently referred to our vascular surgery clinic, and a computed tomography angiogram was obtained demonstrating a 7.4-cm aortic aneurysm. Within the aneurysm sac there were three previously placed main body stent grafts: a Cook Zenith (Cook Medical, Bloomington, Ind) placed at the aortic neck and two AneuRx stent grafts (Medtronic, Minneapolis, Minn) extending into the right and left iliac bifurcations (A/Cover). Both external iliac stent graft limbs and arteries were patent, whereas both internal iliac limbs and arteries were occluded. The main body components were completely dissociated from one another, resulting in a type III endoleak, aneurysm sac repressurization, and an additional 2.3-cm growth in aneurysm diameter beyond its originally repaired size.Endovascular repair of the type III endoleak was performed by remote access through the bilateral common femoral arteries and left brachial artery. Through-wires were placed from each femoral access site out the brachial artery site. The "body floss" technique helped provide stability to straighten the free-floating pre-existing stent graft ends and served as a secure rail to pass the iliac limb delivery systems. Cook Zenith iliac limbs were used to match the proximal sealing main body device (B). Follow-up imaging demonstrated resolution of the endoleak, widely patent stent graft limbs, and a reduction in size of the aneurysm sac to 5 cm. DISCUSSIONThis case presents a stark realization of the consequences of deviating from aortic stent graft instructions for use (IFU) guidelines. 1 In our patient, recommendations regarding anatomic suitability, matching modular components designed and validated to work with one another, and postoperative surveillance protocols were disregarded. Failure of adherence to IFU-specified guidelines resulted in aortic aneurysm From the

Background As immediate direct to permanent implant-based breast reconstruction (IBBR) continues to gain in popularity, surgeons seek to apply these techniques to patients with large or ptotic breasts. A new bell pattern skin excision is described and limits major complications in this high-risk population. Objective The authors describe a novel skin excision pattern for patients with large or ptotic breasts who desire IBBR and assess its safety. The authors also evaluated the ability of the pattern to account for intraoperative developments. Methods This retrospective analysis of a single surgeon’s experience included 17 consecutive patients (31 breasts) with large or ptotic breasts undergoing skin-reducing mastectomy with attempted utilization of the bell pattern approach and IBBR with acellular dermal matrix. Results Mean age was 50 years, mean body mass index was 27.4 kg/m2, and mean breast specimen weight was 683g. A bell pattern excision was planned for all breasts preoperatively. Three breasts (10%) required an alternative closure pattern due to intraoperative ischemia (n=1), or additional oncologic resection (n=2). The pattern successfully accommodated flap ischemia in 8 (26%) other breasts. After a median follow up of 5.1 months, the number of bell pattern breasts with major and minor complications was 0 (0%) and 9 (32%), respectively. The most common minor complication was seroma (n=5, 18%), and minor incision wound (n=3, 11%). There were no reconstruction failures utilizing the bell pattern. Conclusion The bell pattern approach is a safe and adaptable alternative to traditional skin-reducing mastectomy in patients with large or ptotic breasts.