Muscle Complex Research Articles

New insights into muscle function during pivot feeding in seahorses.

Seahorses, pipefish and their syngnathiform relatives are considered unique amongst fishes in using elastic recoil of post-cranial tendons to pivot the head extremely quickly towards small crustacean prey. It is known that pipefish activate the epaxial muscles for a considerable time before striking, at which rotations of the head and the hyoid are temporarily prevented to allow energy storage in the epaxial tendons. Here, we studied the motor control of this system in seahorses using electromyographic recordings of the epaxial muscles and the sternohyoideus-hypaxial muscles with simultaneous high-speed video recordings of prey capture. In addition we present the results from a stimulation experiment including the muscle hypothesised to be responsible for the locking and triggering of pivot feeding in seahorses (m. adductor arcus palatini). Our data confirmed that the epaxial pre-activation pattern observed previously for pipefish also occurs in seahorses. Similar to the epaxials, the sternohyoideus-hypaxial muscle complex shows prolonged anticipatory activity. Although a considerable variation in displacements of the mouth via head rotation could be observed, it could not be demonstrated that seahorses have control over strike distance. In addition, we could not identify the source of the kinematic variability in the activation patterns of the associated muscles. Finally, the stimulation experiment supported the previously hypothesized role of the m. adductor arcus palatini as the trigger in this elastic recoil system. Our results show that pre-stressing of both the head elevators and the hyoid retractors is taking place. As pre-activation of the main muscles involved in pivot feeding has now been demonstrated for both seahorses and pipefish, this is probably a generalized trait of Syngnathidae.

Manejo miofuncional de mordida abierta anterior en un paciente con reabsorción radicular apical externa severa de incisivos superiores

Root resorption is a complication of orthodontic treatment that may occur in various degrees of severity. However, considerable root resorption can also be appreciated in patients where root development has been interrupted by different circumstances during the orthodontic treatment. A 9-year-old female patient was admitted after being in a treatment with fixed appliances for 3 years. She presented clinical features of anterior open bite and the radiographic evaluation showed important root resorption of the four maxillary incisors. It was decided to use a more conservative approach instead of fixed appliances during the initial phase of treatment and a myofunctional therapy was chosen. Assessment of the upper airways was performed before placing a tongue crib accompanied by exercises of the orbicularis oris muscle complex, after one month of follow-up appointments, bite closure was obtained. Chances of relapse are reduced with appropriate growth guidance and changes in the muscular behavior of young patients.

Myofunctional approach for open bite correction in a patient with severe upper incisor external apical root resorption

Root resorption is a complication of orthodontic treatment that may occur in various degrees of severity. However, considerable root resorption can also be appreciated in patients where root development has been interrupted by different circumstances during the orthodontic treatment. A 9-year-old female patient was admitted after being in a treatment with fixed appliances for 3 years. She presented clinical features of anterior open bite and the radiographic evaluation showed important root resorption of the four maxillary incisors. It was decided to use a more conservative approach instead of fixed appliances during the initial phase of treatment and a myofunctional therapy was chosen. Assessment of the upper airways was performed before placing a tongue crib accompanied by exercises of the orbicularis oris muscle complex, after one month of follow-up appointments, bite closure was obtained. Chances of relapse are reduced with appropriate growth guidance and changes in the muscular behavior of young patients.

Alcohol impairs skeletal muscle protein synthesis and mTOR signaling in a time-dependent manner following electrically stimulated muscle contraction.

Alcohol (EtOH) decreases protein synthesis and mammalian target of rapamycin (mTOR)-mediated signaling and blunts the anabolic response to growth factors in skeletal muscle. The purpose of the current investigation was to determine whether acute EtOH intoxication antagonizes the contraction-induced increase in protein synthesis and mTOR signaling in skeletal muscle. Fasted male mice were injected intraperitoneally with 3 g/kg EtOH or saline (control), and the right hindlimb was electrically stimulated (10 sets of 6 contractions). The gastrocnemius muscle complex was collected 30 min, 4 h, or 12 h after stimulation. EtOH decreased in vivo basal protein synthesis (PS) in the nonstimulated muscle compared with time-matched Controls at 30 min, 4 h, and 12 h. In Control, but not EtOH, PS was decreased 15% after 30 min. In contrast, PS was increased in Control 4 h poststimulation but remained unchanged in EtOH. Last, stimulation increased PS 10% in Control and EtOH at 12 h, even though the absolute rate remained reduced by EtOH. The stimulation-induced increase in the phosphorylation of S6K1 Thr(421)/Ser(424) (20-52%), S6K1 Thr(389) (45-57%), and its substrate rpS6 Ser(240/244) (37-72%) was blunted by EtOH at 30 min, 4 h, and 12 h. Phosphorylation of 4E-BP1 Ser(65) was also attenuated by EtOH (61%) at 4 h. Conversely, phosphorylation of extracellular signal-regulated kinase Thr(202)/Tyr(204) was increased by stimulation in Control and EtOH mice at 30 min but only in Control at 4 h. Our data indicate that acute EtOH intoxication suppresses muscle protein synthesis for at least 12 h and greatly impairs contraction-induced changes in synthesis and mTOR signaling.

Role of primary closure after transoral robotic surgery for tonsillar cancer.

This study was performed to verify the efficacy and feasibility of primary closure for communication defects in the neck after transoral robotic surgery (TORS) for tonsillar cancer, and to verify the necessity of en bloc resection, which can create communication defects during TORS. We applied a new primary closure technique in 13 cases of tonsillar cancer showing a communication defect with the neck after en bloc resection during TORS. This technique is composed of three steps: (1) suturing the remaining superior pharyngeal constrictor muscle and extrinsic tongue muscle complex; (2) suturing the digastric and mylohyoid muscles; and (3) securing reinforcement of the digastric-mylohyoid complex. We analyzed the medical records and pathology reports of these cases. On pathology review, 69.2% of the patients developed invasion of the constrictor muscle. The mean defect size was 3.3 cm; the largest defect was 4.5 cm in diameter. In all patients, primary closure of the defect was possible. With regard to functional results, decannulation was possible within 1 week, oral feeding was possible within 9 days, and none of the patients showed pharyngocutaneous fistula formation. Two patients developed complications independent of the surgery itself. The invasion rate of the pharyngeal constrictor muscle is high. Therefore, en bloc resection creating a communication defect during TORS should be considered in all cases of tonsillar cancer to secure safe margins. In addition, with our primary closure technique, even large defects can be closed without complication and with good preservation of function.

Asociación de malformación anorrectal con duplicaciones anales y rectales

El objetivo de este trabajo es compartir la experiencia en el diagnóstico y tratamiento de casos de duplicaciones rectales y anales asociadas con malformación anorrectal. Se reportan dos casos con oclusión intestinal y diagnóstico tardío de la malformación anorrectal tratados inicialmente con laparotomía, anastomosis latero-lateral de la duplicación colónica proximal y co- lostomía y un caso con diagnóstico de malformación anorrectal con fístula recto-perineal al nacimiento al que, al realizarle colostomía, evidenció duplicaciones colónica y rectal relacionadas. En los tres casos se realizó, para su corrección quirúrgica definitiva, un abordaje abdominoperineal y anastomosis latero-lateral de la duplicación rectal, colocación del recto dentro del complejo muscular anorrectal y poste- rior cierre de la colostomía. En un cuarto paciente con malformación anorrectal sin fístula clínicamente evidente y colostomía al nacimiento, la electroestimulación perineal evidenció dos complejos musculares a los que se les realizó un abordaje sagital, observándose dos fondos de sacos ciegos rectales separados. Se realizó anastomosis termino-lateral del recto duplicado y se decidió utilizar el complejo con mayor acti- vidad contráctil para la colocación del neoano. Consideramos que el abordaje sagital posterior es la mejor opción quirúrgica para preservar el complejo muscular con mejor pronóstico para la continencia fecal.

Esophagus tissue engineering: designing and crafting the components for the "hybrid construct" approach.

Although being a tubular structure, the esophagus is an extremely complex organ to engineer. To engineer an organ, its components and their structure and function must be well understood. With regards to esophagus, extensive investigations have been performed in experimental models to understand the nature of the esophageal epithelial cells with regards to their isolation, culture, and growth on scaffolds to generate epithelium. Special subpopulations of these cells have been identified that possess proliferative capabilities with subsequent differentiative capacity to generate epithelium. Studies have also been performed to obtain data on the possibilities of utilizing esophageal biopsies from esophagus damaged after caustic exposure for tissue engineering applications. Subsequently, attention is being paid to the esophageal smooth muscle which is an extremely complex structure responsible for the propulsive activities. In addition to the muscle complex, proper functioning of the esophagus will require understanding of the enteric nervous system (ENS) that controls the propulsive activity in a coordinated manner. Investigations have been performed to better understand the esophageal ENS and to isolate and maintain these cells under tissue culture conditions. Besides the cellular elements, studies have also been performed to seed these cells on scaffolds and study the constructs with regards to cell attachment and viability under tissue culture conditions. Tests have also been performed on native esophageal tissue to understand the functioning of this tissue under the effect of pharmacological agents and to establish norms to compare engineered esophageal tissue. Vascularization, which is a limiting factor in tissue engineering, has been approached with the in situ bioreactor concept using the omentum not only to provide vascular ingrowth but also to offer a pedicle for the engineered esophagus to enable its surgical transposition. This review offers an insight into the advances in esophagus tissue engineering in a large experimental model using the "hybrid construct" approach which advocates the precise engineering of the tubular gastrointestinal organs based on growth of specific cells on specially designed scaffolds and amalgamating them to create the desired complex tissue structure.

Transcriptional regulation of myotrophic actions by testosterone and trenbolone on androgen-responsive muscle

Androgens regulate body composition and skeletal muscle mass in males, but the molecular mechanisms are not fully understood. Recently, we demonstrated that trenbolone (a potent synthetic testosterone analogue that is not a substrate for 5-alpha reductase or for aromatase) induces myotrophic effects in skeletal muscle without causing prostate enlargement, which is in contrast to the known prostate enlarging effects of testosterone. These previous results suggest that the 5α-reduction of testosterone is not required for myotrophic action. We now report differential gene expression in response to testosterone versus trenbolone in the highly androgen-sensitive levator ani/bulbocavernosus (LABC) muscle complex of the adult rat after 6weeks of orchiectomy (ORX), using real time PCR. The ORX-induced expression of atrogenes (Muscle RING-finger protein-1 [MuRF1] and atrogin-1) was suppressed by both androgens, with trenbolone producing a greater suppression of atrogin-1 mRNA compared to testosterone. Both androgens elevated expression of anabolic genes (insulin-like growth factor-1 and mechano-growth factor) after ORX. ORX-induced increases in expression of glucocorticoid receptor (GR) mRNA were suppressed by trenbolone treatment, but not testosterone. In ORX animals, testosterone promoted WNT1-inducible-signaling pathway protein 2 (WISP-2) gene expression while trenbolone did not. Testosterone and trenbolone equally enhanced muscle regeneration as shown by increases in LABC mass and in protein expression of embryonic myosin by western blotting. In addition, testosterone increased WISP-2 protein levels. Together, these findings identify specific mechanisms by which testosterone and trenbolone may regulate skeletal muscle maintenance and growth.

Echographic study of extraocular muscle thickness in normal Indian population

PurposeTo establish normative data of extraocular muscle (EOM) dimensions, both vertically and horizontally, using a reproducible echographic method in various age groups. MethodsTwo hundred eyes of 100 healthy subjects (50 males and rest females) were included in this prospective observational study. All subjects were divided into 5 groups with an interval of 10years from 10 to 60years. Each group contained 10 male and 10 female healthy subjects. A single operator took measurements at 4mm distance from the globe plane after drawing a perpendicular line on the globe to the muscle belly. ResultsThe average age of subjects was 37.28±17.14years. Intraobserver reproducibility was very high (intersession concordance correlation co-efficient=0.995). Mean horizontal and vertical diameters of recti were 3.0775 and 8.26mm, respectively. Mean muscle thickness of superior rectus/levator palpebral superioris (LPS) muscle complex and LPS was 4.56 and 1.45mm, respectively. Extraocular muscle diameter increases up to the middle age, then it starts decreasing. There was no statistically significant correlation between diameter of each EOM, both eye and gender (p⩾0.05). There was a non-significant change in extraocular muscle thickness with age. ConclusionThe study provides normative data for extraocular muscle thickness in both genders of various age groups in Indian population. Muscle dimensions do not change significantly with age, between the eyes and gender.

Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging?

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years (SD ± 10.76), the mean body mass index (BMI) was 28.36 (SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 (SD ± 4.94) and 11.53 (SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

421 Role of Wnt-β Catenin Signaling in Anal Sphincter Injury & Repair

Background and Aims: Our recent studies to unravel pathophysiology of childbirth related injury to the anal sphincter muscle complex revealed anatomical disruptions1, increased fibrosis and impaired sphincter muscle function. Molecular mechanism of sphincter muscle fibrosis is unclear. Wnt-β catenin signaling pathway is recently recognized as the major molecular pathway involved in organ fibrosis2. The goal of our study was to specifically examine the role of this novel pathway in anal sphincter injury-related fibrosis and evaluate if intervention of this signaling pathway using a specific antagonist (SFRP2-secreted frizzled related protein-2) could attenuate fibrosis and improve EAS muscle function. Methods: New Zealand White female rabbits (n=12) were subjected to surgical myotomy by a cranio-caudal incision that extended along the entire length and thickness of the EAS muscle. Half of these animals received injection of Wnt antagonist (SFRP22 μg/200μl, daily X 5 days) and the rest received saline (placebo group) at the myotomy site. Physiological measurements (anal canal pressure; length-tension function) were recorded at weekly intervals for 12 weeks post-myotomy. Animals were sacrificed at pre-determined time points and anal canal was harvested and processed for histochemical studies (Masson trichrome stain for muscle / connective tissue and Sirius red for collagen), immunostaining (β catenin) and molecular evaluation (Western blot & qPCR) for markers of fibrosis (collagen, connective tissue growth factor). Results: Surgical myotomy of the EAS resulted in significant impairment in anal canal pressure (Panel A-top) and L-T function. Immunostaining studies showed activation of Wnt-β catenin signaling pathway (Panel B) after injury. Molecular studies revealed 1.5 to 2 fold increase in levels of fibrosis markers (collagen, connective tissue growth factor). Treatment with SFRP-2 attenuated functional impairment (Panel A; as evidenced by improvement in anal canal pressure; Panel A-bottom), suppressed activation of β catenin (Panel B) and prevented fibrosis development (Panel C). Conclusions: Improvement in sphincter muscle function after selective inhibition of Wnt/β-catenin signaling suggests a novel therapeutic potential for prevention of anal sphincter dysfunction consequent to sphincter injury.

Imaging appearance of the lateral rectus-superior rectus band in 100 consecutive patients without strabismus.

The lateral rectus-superior rectus band is an orbital connective tissue structure that has been implicated in a form of strabismus termed sagging eye syndrome. Our purpose was to define the normal MR imaging and CT appearance of this band in patients without strabismus. Orbital MR imaging and CT examinations in 100 consecutive patients without strabismus were evaluated. Readers graded the visibility of the lateral rectus-superior rectus band on coronal T1WI, coronal STIR, and coronal CT images. Readers determined whether the band demonstrated superotemporal bowing or any discontinuities and whether a distinct lateral levator aponeurosis was seen. Reader agreement was assessed by κ coefficients. Association between imaging metrics and patient age/sex was calculated by using the Fisher exact test. The lateral rectus-superior rectus band was visible in 95% of coronal T1WI, 68% of coronal STIR sequences, and 70% of coronal CT scans. Ninety-five percent of these bands were seen as a continuous, arc-like structure extending from the superior rectus/levator palpebrae muscle complex to the lateral rectus muscle; 24% demonstrated superotemporal bowing; and in 82% of orbits, a distinct lateral levator aponeurosis was visible. Increasing patient age was negatively associated with lateral rectus-superior rectus band visibility (P=.03), positively associated with lateral rectus-superior rectus band superotemporal bowing (P=.03), and positively associated with lateral levator aponeurosis visibility (P=.01). The lateral rectus-superior rectus band is visible in most patients without strabismus on coronal T1WI. The age effect with respect to its visibility and superotemporal bowing could represent age-related connective tissue degeneration.

Combined Cystometrography and Electromyography of the External Urethral Sphincter Following Complete Primary Repair of Bladder Exstrophy

Concern in patients with bladder exstrophy after reconstruction regarding potential injury to pelvic neurourological anatomy and a resultant functional deficit prompted combined (simultaneous) cystometrography and electromyography after complete primary repair of bladder exstrophy. We determined whether complete primary repair of bladder exstrophy would adversely affect the innervation controlling bladder and external urethral sphincter function. Complete primary repair of bladder exstrophy was performed via a modified Mitchell technique in newborns without osteotomy. Postoperative evaluation included combined cystometrography and needle electrode electromyography via the perineum, approximating the external urethral sphincter muscle complex. Electromyography was done to evaluate the external urethral sphincter response to sacral reflex stimulation and during voiding. Nine boys and 4 girls underwent combined cystometrography/electromyography after complete primary repair of bladder exstrophy. Age at study and time after complete primary repair of bladder exstrophy was 3 months to 10 years (median 11.5 months). Cystometrography revealed absent detrusor overactivity and the presence of a sustained detrusor voiding contraction in all cases. Electromyography showed universally normal individual motor unit action potentials of biphasic pattern, amplitude and duration. The external urethral sphincter sacral reflex response was intact with a normal caliber with respect to Valsalva, Credé, bulbocavernosus and anocutaneous (bilateral) stimulation. Synergy was documented by abrupt silencing of external urethral sphincter electromyography activity during voiding. After complete primary repair of bladder exstrophy combined cystometrography/electromyography in patients with bladder exstrophy showed normal neurourological findings, including sacral reflex responses, sustained detrusor voiding contraction and synergic voiding, in all patients postoperatively. These findings confirm the safety of complete primary repair of bladder exstrophy. Based on our results we have discontinued routine electromyography in these patients.

Three Dimensional Transperineal Ultrasonography of the Pelvic Floor

: Ultrasound images have replaced conventional radiology as the modality of choice for imaging the female patients with voiding dysfunction and evaluation of pelvic floor function. Transvaginal, introital, and perineal ultrasound can all be performed with 3D and Doppler options. Recommended bladder filling to ensure reliability and reproducibility of obtained data is about 300 ml. Urethral funneling is more pronounced in an appropriately filled bladder. Prolapse is less apparent when pressing with a full bladder than with a partially filled bladder. 3D ultrasound sectional images are replacing MRI because of an equivalent resolution and the added advantage of ease of utility, dynamic display, and vascular display. Once the midsagittal view of the pelvic floor is obtained, the patient can be asked to strain, and a cine loop of the action can be recorded, allowing relative organ position changes to be assessed. The major muscle of the pelvic floor is the levator ani. The muscle complex spans the space between the obturator internus muscle laterally, the pubis symphysis anteriorly and the coccyx posteriorly. Levator ani muscles support the pelvic floor and counteract the pressure by contracting and creating a circular closing of the levator hiatus and an upward movement of the pelvic floor and perineum. The indices for evaluation of anterior compartment are H (distance between the bladder neck and a line through the lower edge of the pubic symphysis) and B (posterior urethrovesical angle). These indices are determined at rest, during the Valsalva maneuver, and during pelvic floor contraction. Normal range of H is 20.6 mm at rest and 14.0 mm during strain. Normal posterior urethrovesical angle is 96.8 at rest and 108.1during strain. The posterior compartment elements (internal sphincter, external sphincter, and longitudinal muscles) also can be evaluated with sonography. Four ultrasonographic signs of sphincter damage include thickening of the ES at the 12-oclock position, thinning of the IS in the area of rupture with thickening opposite the rupture site (the half-moon sign), IS/ES discontinuity and abnormality of the mucous folds.

Laryngeal Muscle Activity in Unilateral Vocal Fold Paralysis Patients Using Electromyography and Coronal Reconstructed Images

To assess laryngeal muscle activity in unilateral vocal fold paralysis (UVFP) patients using laryngeal electromyography (LEMG) and coronal images. Case series with chart review. University hospital. Twenty-one patients diagnosed with UVFP of at least 6 months in duration with paralytic dysphonia, underwent LEMG, phonatory function tests, and coronal imaging. A 4-point scale was used to grade motor unit (MU) recruitment: absent = 4+, greatly decreased = 3+, moderately decreased = 2+, and mildly decreased = 1+. Maximum phonation time (MPT) and mean flow rate (MFR) were employed. Coronal images were assessed for differences in thickness and vertical position of the vocal folds during phonation and inhalation. MU recruitment in thyroarytenoid/lateral cricoarytenoid (TA/LCA) muscle complex results were 1+ for 4 patients, 2+ for 5, 3+ for 6, and 4+ for 6. MPT was positively correlated with MU recruitment. Thinning of the affected fold was evident during phonation in 19 of the 21 subjects. The affected fold was at an equal level with the healthy fold in all 9 subjects with MU recruitment of 1+ and 2+. Eleven of 12 subjects with MU recruitments of 3+ and 4+ showed the affected fold at a higher level than the healthy fold. There was a significant difference between MU recruitment and the vertical position of the affected fold. Synkinetic reinnervation may occur in some cases with UVFP. MU recruitments of TA/LCA muscle complex in UVFP patients may be related to phonatory function and the vertical position of the affected fold.

Subconjunctival cysticerscosis with involvement of superior muscle complex - a case report

Cysticercosis is a parasitic infestation caused by cysticercus cellulose. Ocular and adnexal cysticercosis represents 13% to 46% of systemic disease. There are different modes of presentation of ocular cysticercosis. Case: Here we report a case with the left upper eyelid ptosis. On ocular examination, there was presence of a cystic yellowish mass of size of the eye ball in the upper palpebral sub-conjunctiva along with dystropia and limitation of extraocular movements in dextroelevation. Complete surgical excision of the cyst was achieved through splitting of the left upper eyelid. There was presence of sub-conjunctival cyst along with involvement of levator palpebral superioris (LPS) and superior rectus (SR) muscle. Histopathological examination of the cyst showed features suggestive of cysticercosis. The patient was symptomatically better postoperatively. He was commenced on oral prednisolone 1mg/kg and oral albendazole 400 mg for 28 days. Conclusion: Cysticercosis should be considered in cases of inflammatory swelling of subconjunctival space especially in people with poor personal and community hygiene. DOI: http://dx.doi.org/10.3126/hren.v11i3.9659 Health Renaissance 2013;11(3):293-296

99m Tc-sulfadimidine as a potential radioligand for differentiation between septic and aseptic inflammations

Sulfadimidine, a bacteriostatic drug blocking folic acid synthesis, was labeled with 99mTc producing a yield of about 90%. The optimum conditions required to obtain 90% yield of the 99mTc complex were as follows: 500 μg of sulfadimidine, 100 μg of SnCl2·2H2O, 5 min, room temperature (25 ± 1°C), pH 4 (0.5 M citrate buffer). The radiochemical purity of the labeled compound was determined using paper and thin-layer chromatography. Biodistribution study in normal mice showed high uptake of the 99mTc complex in stomach and intestine. The ratio of the uptake of the 99mTc complex in muscles infected with E. coli to that in normal mice was about 2, 1.5 and 1.4 at 15, 90, and 180 min post injection, respectively, whereas for the muscles inflamed with heat-killed E. coli or sterile turpentine oil the difference from the normal muscles was insignificant.

Surgical Correction of Blepharoptosis Using a Modified Levator Aponeurosis–Müller Muscle Complex Reinsertion Technique

The purpose of this study was to evaluate the outcomes after ptosis correction surgery using a modified levator aponeurosis-Müller muscle complex reinsertion technique. In this clinical study, 75 eyelids of 49 patients with congenital blepharoptosis were treated with the modified technique. The results, including complications, were followed up and evaluated. Operation was performed via anterior transcutaneous incision. After separating the preseptal orbicularis oculi muscle, the levator complex, including Müller muscle and the levator aponeurosis, was visualized. The levator complex was cut into 2 parts at the top of the conjunctival fornix to create an upper portion and a lower portion. The detached lower portion of the complex flap combined with the tarsal plate was advanced superiorly and reinserted into the posterior aspect of the upper portion of the complex flap by using 3 horizontal mattress sutures. Preoperative ptosis severity was compared with the degree of ptosis correction using the Cochran-Mantel-Haenszel test. Preoperative levator function was compared with the degree of ptosis correction and the postoperative levator function using Fisher exact test for paired data. Sufficient postoperative correction of ptosis was achieved in 78.7% of eyelids. Postoperative levator function of more than 4 mm was achieved in 82.7% of all eyelids that underwent surgery. We conclude that the modified levator aponeurosis-Müller muscle complex reinsertion technique is effective for correcting congenital blepharoptosis, especially in patients with fair to good (>4 mm) preoperative levator function.

COMPLETE PENILE DISASSEMBLY FOR ISOLATED EPISPADIAS REPAIR WITH MITCHELL-CAIONE TECHNIQUE: TWO CASES

Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Many surgical technique have been described for repair of male epispadias. The aim of surgical repair is to get cosmetically acceptable and functional penis with a ventrally located urethra opening at the tip of the glans and moreover to give the patient a urinary continence. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. We present two cases of our experience where we used the complete penile disassembly tecnique by Mitchell-Caione in wich we acts on the voluntary control of urination by the reapproximation of the muscular plane of pelvic diaphragm and elevator muscle around the posterior urethra reconstructed. Epispadias repairs was performed on two incontinent male epispadias patient, aged 2 to 3 years. Both cases were untreated. Complete disassembly of penil components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies and the glans were split on the sagittal plane according to Grady-Mitchell. The central portion of the urethral plate was preserved intact. An electric stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. “Z plasties” were necessary according to initial urethral length and width: the urethra was reconstructed over a double catheters, using 5/0 polyglicolic acid interrupted sutures in a single layer. In one patient we sutured symphisis pubis opened precedently, using 1/0 polyglicolic acid. The urethra was placed ventrally in the reconstructed shaft under the two corpora as Mitchell technique. Glanduloplasty was then performed. Patients were followed up for one month (June 2012). The penis of the two patients had a satisfactory cosmetic appearance with no dorsal chordee. Morover, our patients obtained urinary continence. The limitation of our study was the low follow-up. The electric stimulator used to identify pelvic muscle components in the sagittal plane for reapproximate the posterior tabularized urethra to form the periurethral muscle complex and the “Z-plasties” that elongated the urethra significantly.This procedure seems to be satisfactory for the repair of cases of isolated male epispadias because we have good results in cosmetic appearance and in urinary continence. Our study is a preliminary report and a longer follow-up with a larger number of cases is needed to document further the success of the procedure.

COMPLETE PENILE DISASSEMBLY FOR ISOLATED EPISPADIAS REPAIR WITH MITCHELL-CAIONE TECHNIQUE: TWO CASES

Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Many surgical technique have been described for repair of male epispadias. The aim of surgical repair is to get cosmetically acceptable and functional penis with a ventrally located urethra opening at the tip of the glans and moreover to give the patient a urinary continence. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. We present two cases of our experience where we used the complete penile disassembly tecnique by Mitchell-Caione in wich we acts on the voluntary control of urination by the reapproximation of the muscular plane of pelvic diaphragm and elevator muscle around the posterior urethra reconstructed. Epispadias repairs was performed on two incontinent male epispadias patient, aged 2 to 3 years. Both cases were untreated. Complete disassembly of penil components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies and the glans were split on the sagittal plane according to Grady-Mitchell. The central portion of the urethral plate was preserved intact. An electric stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. “Z plasties” were necessary according to initial urethral length and width: the urethra was reconstructed over a double catheters, using 5/0 polyglicolic acid interrupted sutures in a single layer. In one patient we sutured symphisis pubis opened precedently, using 1/0 polyglicolic acid. The urethra was placed ventrally in the reconstructed shaft under the two corpora as Mitchell technique. Glanduloplasty was then performed. Patients were followed up for one month (June 2012). The penis of the two patients had a satisfactory cosmetic appearance with no dorsal chordee. Morover, our patients obtained urinary continence. The limitation of our study was the low follow-up. The electric stimulator used to identify pelvic muscle components in the sagittal plane for reapproximate the posterior tabularized urethra to form the periurethral muscle complex and the “Z-plasties” that elongated the urethra significantly.This procedure seems to be satisfactory for the repair of cases of isolated male epispadias because we have good results in cosmetic appearance and in urinary continence. Our study is a preliminary report and a longer follow-up with a larger number of cases is needed to document further the success of the procedure.