Pitx2 is a bicoid-related homeobox transcription factor implicated in regulating left-right patterning and organogenesis. However, only a limited number of Pitx2 downstream target genes have been identified and characterized. Here we demonstrate that Pitx2 is a transcriptional repressor of DEP domain containing 1B (DEPDC1B). The first intron of the human and mouse DEP domain containing 1B genes contains multiple consensus DNA-binding sites for Pitx2. Chromatin immunoprecipitation assays revealed that Pitx2, along with histone deacetylase 1, was recruited to the first intron of Depdc1b. In contrast, RNAi-mediated depletion of Pitx2 not only enhanced the acetylation of histone H4 in the first intron of Depdc1b, but also increased the protein level of Depdc1b. Luciferase reporter assays also showed that Pitx2 could repress the transcriptional activity mediated by the first intron of human DEPDC1B. The GAP domain of DEPDC1B interacted with nucleotide-bound forms of RAC1 in vitro. In addition, exogenous expression of DEPDC1B suppressed RAC1 activation and interfered with actin polymerization induced by the guanine nucleotide exchange factor TRIO. Moreover, DEPDC1B interacted with various signaling molecules such as U2af2, Erh, and Salm. We propose that Pitx2-mediated repression of Depdc1b expression contributes to the regulation of multiple molecular pathways, such as Rho GTPase signaling.
Summary The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.
Background: Skeletal muscle lacerations are a relatively common injury. Compared with nonrepaired lacerations, surgically repaired muscle lacerations regenerate faster, develop less scar tissue, have a higher return to baseline strength, and have lower incidence of hematomas. Despite the benefits of repair, the optimal repair technique is still unknown. The purpose of this study was to examine the biomechanical properties of common muscle repair techniques to determine the optimal repair. Methods: Forty-two fusiform porcine muscle specimens were dissected and used for this study. Three suture techniques were used for comparative analysis: Figure-eight, Mason Allen, and Perimeter. Each muscle was transected and then repaired using one of the 3 techniques. Fourteen muscle-tendon specimens were prepared for each group and tested for tensile failure using a material testing system. Biomechanical properties, including peak failure point and stiffness, were compared for differences between the suture groups by 1-way analysis of variance. The average time per repair technique was also recorded. Results: The Perimeter technique showed a statistically significant higher peak failure point than the Mason Allen technique (P = .03). Both the Figure-eight (P = .047) and Perimeter techniques (P < .001) were significantly stiffer than the Mason Allen technique. The repair time was comparable across all 3 techniques. Conclusions: The Figure-eight and Perimeter repairs were found to be similar in peak failure point and stiffness, whereas the Mason Allen technique showed significantly lower stiffness and peak failure point. The Figure-eight was the quickest repair to perform. The Figure-eight technique may be strongly considered for muscle laceration repairs due to its simplicity and efficiency.
The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment. Preoperative testing is a key element in identifying high-risk scenarios, and preoperative testing protocols are essential to maintaining safety in the COVID-19 era. Because COVID-19 can be transmitted via the conjunctiva, adaptations to loupes and microscopes are necessary to safely perform microsurgery in high-risk scenarios. We outline a potential risk stratification algorithm, as well as precautions for each scenario. Potential areas for innovation are also discussed.
Background: Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery. Methods: An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block. The study was conducted as an institutional review board–approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included. The patients were separated into pre-ERAS and ERAS cohorts. Data on demographic characteristics, postanesthesia care unit (PACU) length of stay, PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions were collected. Analysis was performed with the Fisher exact test or chi-square test as appropriate. Results: Group 1 (pre-ERAS) and group 2 (ERAS) each included 68 patients. The cohorts had similar age, body mass index, diabetes status, and tobacco use. Group 1 was prescribed an average of 216 OMEs, compared with 126.4 OMEs for group 2, a 41.5% decrease (P < 0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group (P = 0.005). Fewer patients in the ERAS group required additional prescriptions for narcotic pain medication at postoperative follow-up (P = 0.116). No differences were seen in major or minor complications. Conclusion: An ERAS protocol that uses a multimodal approach to pain control and preoperative patient education is useful in the outpatient setting and can help decrease opioid consumption. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Background: Transversus abdominis plane blocks can improve pain control and decrease opioid use within an enhanced recovery after surgery (ERAS) protocol in patients undergoing abdominally based autologous breast reconstruction. The authors have transitioned to using a local analgesic cocktail for transversus abdominis plane blocks. The purpose of this study was to compare postoperative opioid use in patients who received the blocks. Methods: Patients who underwent abdominally based autologous breast reconstruction between November of 2015 and December of 2019 were retrospectively reviewed. The study group received bupivacaine, ketorolac, dexmedetomidine, and dexamethasone; the control group received liposomal bupivacaine with or without bupivacaine, ketorolac, or dexmedetomidine, as a transversus abdominis plane block. The primary outcome of interest was postoperative opioid use and pain scores. Results: One hundred four women met inclusion criteria: 36 in group A (before ERAS, before transversus abdominis plane block), 38 in group B (ERAS, transversus abdominis plane block with liposomal bupivacaine), and 30 in group C (ERAS, transversus abdominis plane block with local anesthetic cocktail). Total daily oral morphine equivalent consumption (group A, 633; group B, 240; group C, 135; p < 0.0001) and average daily oral morphine equivalent consumption (group A, 137; group B, 56; group C, 29; p < 0.0001) were significantly less for group C in the inpatient phase. Patients in group C were prescribed significantly fewer outpatient oral morphine equivalents (group A, 79; group B, 74; group C, 52; p = 0.01). Conclusions: Transversus abdominis plane blocks are a significant component of an ERAS protocol for abdominally based breast reconstruction. Liposomal bupivacaine is a popular option for transversus abdominis plane blocks. The authors’ results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease postoperative opioid use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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