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Three-dimensional (3D) video exoscopes are high-magnification stereo cameras that project onto monitors mounted in the operating room, viewable from different angles. Outside of plastic surgery, exoscopes have been shown to successfully improve the ergonomics of microsurgery, though sometimes with prolonged operating times. We compare a single surgeon's early experience performing free flap procedures from 2020 to 2021 using either a binocular microscope or a 3D video exoscope. Ten procedures were performed with the standard operating microscope and 8 procedures with the 3D exoscope. The microsurgeon, having minimal prior experience using an exoscope, reported less neck discomfort following the free flap procedures performed with the exoscope compared with the binocular surgical microscope. Total average operating time was comparable between the standard surgical microscope and the 3D exoscope (13.7 vs. 13.4 hours, p = 0.34). Our early experience using a 3D exoscope in place of a standard optical microscope demonstrated that the exoscope shows promise, offering an ergonomic alternative during microvascular reconstruction without increasing overall operating times. Future studies will compare free flap ischemia time between cases performed using the exoscope and the conventional binocular microscope. Medical Subject Headings authorized following words: free tissue flaps; operating rooms; ergonomics; microsurgery.

Introduction Breast surveillance in patients with BRCA mutations include mammography (MMG) and MRI. Patients may elect to undergo risk-reducing bilateral prophylactic mastectomies (BPM). Sentinel lymph node biopsies (SLNB) are frequently performed and associated with increased morbidity. This study sought to determine the correlation between preoperative imaging and the final pathology and evaluate the role of SLNB in these high-risk patients. Methods A prospective database identified BRCA patients who underwent BPM between 2006 and 2022. Imaging, pathology, and operative reports were reviewed. Results 170 patients with BRCA 1/2 mutations were identified. 162 (95.3%) had imaging within one year of BPM. Of these, 28 (17.3%) patients had a MMG/ultrasound, 53 (32.7%) had an MRI, and 81 (50%) had both; 21/162 (13.0%) patients had abnormal imaging. Bilateral SLNB were performed in 31 (18.2%) patients, of which 7 had abnormal imaging; unilateral SLNB were performed in 4 (2.4%) patients, of which 3 had abnormal imaging. 11/170 (6.4%) patients had a malignancy and only one (9%) of these patients had imaging abnormalities. 1/170 (0.6%) patient had an invasive carcinoma requiring an axillary lymph node dissection (ALND), and 10/170 (5.9%) patients had ductal carcinoma in situ (DCIS). 25/170 (14.7%) had ADH/ALH. Only 7/170 (4.1%) patients had imaging abnormalities and abnormal pathology. All SLNB and ALND performed demonstrated no metastatic disease. Discussion There is a high rate of discordance between preoperative imaging prior to surgery in BRCA patients undergoing prophylactic mastectomies and final pathology. This study does not support routine SLNB at the time of BPM.

Post-traumatic lymphedema (PTL) is a complex, debilitating, and potentially common disease which has received limited attention to date. The available literature is reviewed to identify injury patterns and critical lymphatic areas associated with the disease. A deeper understanding of these critical anatomic regions allows the reconstructive surgeon to potentially identify PTL patients earlier in order to apply surgical and nonsurgical interventions in the acute phase, improving lymphatic physiology and, ultimately, patient outcomes. Current diagnostic and treatment approaches are discussed in detail, with a focus on lymphatic microsurgical techniques developed and applied to PTL within the last decade.

Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.

Marjolin’s ulcers (MUs) represent a unique degenerative process that results in malignancy. Classically, sites of previous burns are associated with MU but, in fact, any non-healing wound has been found to be a potential source of degeneration. Malignancies that arise include typically cutaneous squamous cell carcinoma (SCC), but SCC at the site of a previous wound is a more aggressive, lethal variant. This report represents a cautionary case of the management of an open wound and highlights a previously undescribed etiology of an MU in the breast.

Introduction Despite ongoing improvements in burn care around the world, the burden of burn morbidity and mortality has remined a significant challenge in the Middle East due to ongoing conflicts, economic crises, social disparities, and dangerous living conditions. Here, we examine the epidemiology of burn injuries in the Middle East (ME) relative to socio-demographic index (SDI), age, and sex in order to better define regional hotspots that may benefit most from sustainability and capacity building initiatives. Methods Computational modeling from the 2017 Global Burden of Disease (GBD17) database was used to extrapolate burn data about the nineteen countries that define the ME. Using the GBD17, the yearly incidence, deaths, and Disability-Adjusted Life Years (DALYs) from 1990 to 2017 were defined with respect to age and sex as rates of cases, deaths, and years per 100,000 persons, respectively. Mortality ratio represents the percentage of deaths relative to incident cases. Data from 2017 was spatially mapped using heat-mapping for the region. Results Over 27 years in the ME, an estimated 18,289,496 burns and 308,361 deaths occurred causing 24.5 million DALYs. Burn incidence decreased by 5% globally but only 1% in the ME. Although global incidence continued to decline, most ME countries exhibit steady increases since 2004. Compared to global averages, higher mortality rates (2.8% vs 2.0%) and DALYs (205 vs 152 years) were observed in the Middle East during this time although the respective disparities narrowed by 95% and 42% by 2017. Yemen had the worst death and DALY rates all 27 years with 2 and 2.2 times the ME average, respectively. Sudan had the highest morality ratio (3.7%) for most of the study, twice the ME average (1.8%), followed by Yemen at 3.6%. Sex-specific incidence, deaths, and DALYs in the ME were higher compared to the global cohorts. ME women had the worst rates in all categories. With respect to age, all rates were worse in the ME age groups except in those under 5 years. Conclusions For almost three decades, ME burn incidence, deaths, DALYs, and mortality rates were consistently worse than global average. Despite the already significant differences for burn frequency and severity, especially in women and children, underreporting from countries who lack sufficient registry capabilities likely means that the rates are even worse than predicted.

NF-κB is an evolutionarily conserved eukaryotic transcription factor that plays a role in many important developmental and immune-related processes by activating target gene expression. The goal of these experiments was to define the sequences required for a sea anemone NF-κB's intrinsic transactivation activity by using mutant proteins with serial deletions of the N- and C-terminal sequences. Deletion mutants were constructed that were missing the C-terminal 15, 32 or 47 amino acids (aa) or the N-terminal 17, 27 or 47 aa of the 440 aa NF-κB protein from the starlet sea anemone, Nematostella vectensis (Nv), a simple model organism in the phylum Cnidaria. These Nv-NF-κB mutants were expressed as GAL4 fusion proteins in yeast, and their transactivation activities were assessed by LacZ reporter gene assays. The deletion of 47 aa from either the N terminus or the C terminus of NF-κB completely inactivates the transactivation function of Nv-NF-κB. In addition, we identified proline-258 in the center ...

Despite improvements in treatment for T-Acute Lymphoblastic Leukemia (T-ALL), only 70-80% of children and 40% of adults achieve long-term remission. To discover novel targets for the development of molecular therapeutics, we conducted a dominant genetic modifier screen to identify genes whose inactivation delays the onset of leukemia. We have generated a Myc-driven zebrafish model of T-ALL that recapitulates its human counterpart genetically and pathologically. Utilizing this zebrafish model of T-ALL, we conducted a genetic screen that identified a gene encoding dihydrolipoamide S-succinyltransferase (DLST), whose heterozygous loss significantly delays the onset of leukemia in zebrafish. DLST is the E2 component of α-ketogluterate dehydrogenase complex (KGDHC), a key enzyme in the TCA cycle that converts α-ketogluterate (α-KG) to Succinyl CoA. Western blot analysis revealed that DLST was upregulated in zebrafish tumor cells, T-ALL cell lines and primary human T-ALL samples. Zebrafish T-ALL cells with heterozygous inactivation of dlst have decreased cell size and slowed cell cycle progression, compared to T-ALL cells without dlst inactivation. To demonstrate that DLST is a relevant target in human T-ALL, we used two structural analogs of α-KG (α-keto-n-valeric acid sodium salt (KV) and α-keto-β-methyl-n-valeric acid (KMV)) to inhibit the KGDHC activity. Inhibition of KGDHC by both KV and KMV decreased cell viability and promoted apoptotic cell death in a panel of human T-ALL cell lines. Genetic inactivation of DLST, via shRNA knockdown, also decreased cell viability in MOLT16 human T-ALL cell line, confirming the therapeutic potential of DLST in human T-ALL treatment. In vivo treatment of our zebrafish T-ALL model with KV promoted tumor regression within seven days of treatment. Taken together our findings indicate that DLST is an important contributor to T-ALL pathologenesis, and suggest that DLST is a potential target for further therapeutic development to treat human T-ALL. Disclosures: No relevant conflicts of interest to declare.