Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator.

BACKGROUND: It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method. PATIENTS AND METHODS: A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides. RESULTS: The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side. CONCLUSION: The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.

Flap of the sternocephalicus muscle in the repair of a partial defect in the trachea of a rabbit (Oryctolagus cuniculus).

PURPOSE: The current study aimed at evaluating the repair of a partial defect of the trachea with a muscle flap, an advanced technique that employs combined suture patterns. METHODS: Sixteen healthy male New Zealand white rabbits were used as an experimental model. A partial defect in the trachea within the ventral region of the fourth to eighth tracheal ring was created. Subsequently, repair was initiated with a flap of the sternocephalicus muscle. The animals were divided into four groups for postoperative evaluation using clinical, tracheoscopic, and histopathological analyses. Each group was separated according to the time of euthanasia, programmed at interval of seven (G7), 15 (G15), 30 (G30), and 60 days (G60). RESULTS: One animal from the G60 group died, whereas the other animals had good surgical recovery without serious changes in the breathing pattern. The major clinical signs observed were stridor and coughing. Tracheoscopy revealed secretions in the tracheal lumen, exuberant granulation, and stenosis. Histopathological analysis showed growth of the ciliary respiratory epithelium at the flap site 30 days after implantation. CONCLUSIONS: Partial repair showed satisfactory results owing to the anatomical location of the muscle, adequate vascular support, and structural and physiological maintenance without serious changes in the respiratory system.

The Effect of Muscle Quality on Outcomes after Microdiscectomy.

OBJECTIVES: To investigate the relationship between muscle quality and 1) patient-reported outcomes and 2) surgical outcomes after lumbar microdiscectomy surgery. METHODS: Adult patients (≥18 years) who underwent lumbar microdiscectomy from 2014 to 2021 at a single academic institution were identified. Outcomes were collected during the preoperative, 3-month, 6-month, and 1-year postoperative periods. Those included were the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS-Back and VAS-Leg, respectively), and the mental and physical component of the short-form 12 survey (MCS and PCS). Muscle quality was determined by 2 systems: the normalized total psoas area (NTPA) and a paralumbar-based grading system. Surgical outcomes including 90-day surgical readmissions and 1-year reoperations were also collected. RESULTS: Of the 218 patients identified, 150 had good paralumbar muscle quality and 165 had good psoas muscle quality. Bivariant analysis demonstrated no difference between groups regarding surgical outcomes (P > 0.05). Multivariable analysis demonstrated that better paralumbar muscle quality was not associated with any consistent changes in patient reported outcomes. Higher NTPA was associated with improved PCS at 6 months (est. = 6.703, [95% CI: 0.759-12.646], P = 0.030) and 12 months (est. = 6.625, [95% CI: 0.845-12.405], P = 0.027). There was no association between muscle quality and surgical readmissions or reoperations. CONCLUSIONS: Our analysis demonstrated that higher psoas muscle quality was associated with greater physical improvement postoperatively. Muscle quality did not affect surgical readmissions or reoperations. Additional studies are needed for further assessment of the implications of muscle quality on postoperative outcomes.

[The grafted frontalis muscle flap: A simple and efficient lining for aesthetic reconstruction of full thickness nasal sidewall defects]. / Le lambeau du muscle frontal greffé : une technique de doublure simple et efficace dans les rhinopoïèses esthétiques transfixiantes de la face latérale du nez.

The reconstruction of thin and well-vascularized lining is capital for the aesthetic reconstruction of full thickness nasal defects. The mucosal flaps allow such reconstruction, but their dissections are difficult and not always possible, particularly for large defects of the nasal sidewall unit. The grafted frontalis muscle flap allows easily such lining reconstruction. This technique includes 3 stages, all done under local anaesthesia: 1st stage: a vertical paramedian forehead flap is classically raised and it's undersurface is full thickness skin grafted, it is then repositioned on it's site for 4 weeks; 2nd stage: this flap is raised again and split at the level of fat, just superficial to the muscle, in two flaps: the full thickness skin grafted frontalis muscle flap for the lining; and the forehead flap, without it's frontalis muscle, for the skin coverage; a sculpted cartilaginous graft is inserted between these two flaps and sutured to the lining with the aim of obtaining a symmetrical nasal sidewall and the necessary rigidity to avoid the heminasal collapse during inspiration; 3rd stage: 4 weeks after the second stage, the pedicles of these two flaps are severed. No vascular problems and no infections were seen with this technique in 11 patients operated on for evolved basal cell carcinoma of the nasal sidewall since 2018. The aesthetic results were always very satisfactory without any discomfort during breathing.

Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease.

BACKGROUND: Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established. METHODS: A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data. RESULTS: A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053). CONCLUSIONS: Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Aesthetic Evaluation of the Brow-Eye Continuum After Correction of Severe Congenital Ptosis in Children With Extended Frontalis Muscle Advancement Technique.

BACKGROUND: Severe congenital ptosis is a common ocular deformity in pediatric patients that can significantly impact visual development and aesthetic appearance, leading to negative psychosocial outcomes. The frontalis muscle advancement technique is a well-established surgical treatment for severe congenital ptosis. Aesthetic changes of the brow-eye continuum often plays an important role in ptosis surgery. METHODS: We conducted a single-center retrospective case series study of patients with severe congenital ptosis who underwent the frontalis muscle advancement technique at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University between April 2020 and June 2021. The study aimed to evaluate the aesthetic changes of the eyebrow-eyelid continuum after surgery. The main outcome measurements included marginal reflex distance 1, palpebral fissure height, eyebrow position, upper eyelid to lower eyebrow distance, lower eyelid to upper eyebrow distance, and nasal base to lower eyelid distance. RESULTS: The study included 48 patients (66 eyelids), with 30 unilateral and 18 bilateral patients. Our analysis found that eyebrow height decreased by an average of 4.8% postoperatively relative to preoperatively in all patients. CONCLUSIONS: The frontalis muscle advancement technique has demonstrated effectiveness in achieving aesthetically pleasing outcomes in children with severe ptosis. It is crucial to pay careful attention to the brow-eye continuum during the correction process, as its harmony can greatly impact the final result.

Microvascular decompression using autologous muscle graft for trigeminal neuralgia: a case series and meta-analysis.

PURPOSE: We aimed to describe a case series of patients diagnosed with trigeminal neuralgia (TN) who were submitted to microvascular decompression (MVD) using autologous muscle graft (AMG) and perform a systematic review and meta-analysis. METHODS: Forty-four adult patients who underwent MVD using AMG between 2012 and 2022 were studied retrospectively. Demographic, clinical, and surgical factors were assessed. We systematically reviewed PubMed, Embase, and Cochrane Library from inception to May 2023. We used random-effects model for all outcomes. Heterogeneity was assessed with I2. We used R software 4.3.1 for all statistical analyses. RESULTS: Among patients in the case series, the mean age was 52 ± 12.9 years, and the proportion of females was 65.9%. Forty-one patients (93.2%) presented complete pain relief after a mean follow-up of 7.7 years. The pooled analysis of immediate pain relief was 91.3% (95% CI 82-96%; I2=78%). The good pain relief during follow-up was 88.2% (95% CI 78-94%; I2=80%) at follow-up. The recurrence rates at 6, 12, 36 months, and during follow-up were 6.2%, 10.5%, 10.3%, and 11%, respectively. CONCLUSION: In this case series and meta-analysis of over 440 patients, our findings suggest that the practice of MVD using AMG may be an efficient option in the short term as surgical treatment for TN. Further trials should compare AMG with other materials and its effectiveness in a long-term follow-up.

Midterm Outcomes of Muscle-Preserving Posterior Lumbar Decompression via Sagittal Splitting of the Spinous Process: Minimum 5-Year Follow-up.

Background: To overcome several disadvantages of conventional laminectomy for degenerative lumbar spinal stenosis (DLSS), several types of minimally invasive surgery have been developed. The purpose of the present study was to report the clinical and radiological mid-term outcomes of spinous process-splitting decompression (SPSD) for DLSS. Methods: Seventy-three consecutive patients underwent SPSD between September 2014 and March 2016. Of these, 42 (70 segments) who had at least 5 years of follow-up were analyzed retrospectively. The visual analog scale for back pain and leg pain, Oswestry disability index, and walking distance without resting were scored to assess clinical outcomes at the preoperative and final follow-up. A subgroup analysis was performed according to the union status of the split spinous processes (SPs). For radiological outcomes, slip in the neutral position as a static parameter, anterior flexion-neutral translation, and posterior extension-neutral translation as a dynamic parameter were measured before and at the final follow-up after surgery. Spinopelvic parameters were also measured. Reoperation rate at the index levels was investigated, and predictive risk factors for reoperation were evaluated using multivariate logistic regression. Survival analysis was performed with reoperation as the endpoint to estimate the longevity of the SPSD for DLSS. Results: All clinical outcomes improved significantly at the final follow-up compared to those at the initial visit (p < 0.05). The clinical outcomes did not differ according to the union status of the split SP. There were no cases of definite segmental instability and no significant changes in the static or dynamic parameters after surgery. Sacral slope and lumbar lordosis increased, and pelvic tilt decreased significantly at the follow-up (p < 0.05), despite no significant change in the sagittal vertical axis. The mean longevity of the procedure before the reoperation was 82.9 months. Five patients (11.9%) underwent reoperation at a mean of 52.2 months after the SPSD. There were no significant risk factors for reoperation; however, the preoperative severity of foraminal stenosis had an odds ratio of 7.556 (p = 0.064). Conclusions: SPSD for DLSS showed favorable clinical and radiological outcomes at the mid-term follow-up. SPSD could be a good surgical option for treating DLSS.

Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis.

BACKGROUND: Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. METHODS: We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. RESULTS: A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). CONCLUSIONS: Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

A novel ablation strategy for recurrent atrial fibrillation: Fractionated signal area in the atrial muscle ablation 1-year follow-up.

INTRODUCTION: Treatment of recurrent atrial fibrillation (AF) is sometimes challenging due to non-pulmonary vein (PV) foci. Fractionated signal area in the atrial muscle (FAAM) is a valid predictor of the location of non-PV foci. FAAM ablation has the potential to decrease the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF. We compared the clinical impact of FAAM ablation for recurrent AF, using 1 year follow up date. METHODS: A total of 230 consecutive patients with symptomatic recurrent AF who underwent catheter ablation specifically targeting non-PV foci as FAAM-guided ablation (n = 113) and non-FAAM-guided ablation (n = 117) were retrospectively analyzed. FAAM was assigned a parameter (peaks slider, which indicates the number of components of fractionated signals), ranging from 1 to 15, indicating the location of the FAAM (1: largest, 15: smallest). FAAM-guided ablation was performed by ablating FAAM until none inducibility of non-PV foci. On the other hand, non-FAAM-guided ablation was performed via linear ablation, complex fractionated atrial electrogram ablation, superior vena cava isolation, and focal ablation according to the location of the non-PV foci. The RHYTHMIA system was used to perform all the procedures. The primary endpoints were AF recurrence, atrial flutter, and/or atrial tachycardia. RESULTS: After a 1-year follow up, freedom from atrial tachyarrhythmia was achieved in 90.3% and 75.2% of patients in the FAAM and non-FAAM groups, respectively (hazard ratio = 0.438 [95% confidence interval: 0.243-0.788], p = .005). CONCLUSIONS: FAAM ablation showed a promising decrease in the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF during a 1-year follow-up.

Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia.

BACKGROUND: Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness. METHODS: We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia. CONCLUSIONS: All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.

Orbicularis muscle fixation downward for the correction of congenital epiblepharon in Chinese patients.

BACKGROUND: Congenital epiblepharon (CE) is a congenital eyelid deformity unique to young individuals of Asian descendants, and it might cause a sequence of other complications such as corneal damage and ocular foreign body sensation. Surgery is the most effective approach to treat this condition. Here, this study evaluated the effectiveness and safety of the orbicularis muscle fixation downward (OMFD) procedure for correcting CE. METHODS: This study enrolled 29 patients who were diagnosed with CE. These patients experienced significant ocular irritation leading to epiphora and corneal injury and, therefore, they underwent the OMFD procedure that was performed by the same surgeon. The cases were divided into 3 grades according to postoperative outcomes. RESULTS: The OMFD procedure was performed on 55 lower lids of the 29 patients. The average age of the patients was 9.6 years. The mean follow-up duration was 17 months. No perioperative complications were observed, and successful surgical outcomes were achieved in all 29 patients. No postoperative necrosis, infection, or corneal epithelial injury occurred. None of the patients exhibited significant scarring. Three patients showed residual 1-3 eyelashes touching the nasal corneal or bulbar conjunctiva at the inner canthus during the last postoperative examination. These patients did not undergo further surgery as there were no obvious irritation symptoms or corneal damage. CONCLUSIONS: The fixation of the pretarsal orbicularis muscle is a simple and effective modification of the Hotz procedure to correct CE. The key aspect of this procedure is the suturing of the pretarsal orbicularis muscle and the lower eyelid retractors.

Closure of small skull base defects with muscle plug napkin ring technique: how I do it.

BACKGROUND: Defects through the skull base into the paranasal sinuses can occur during anterior skull base procedures, risking cerebrospinal fluid leak and infection if not repaired. METHODS: We describe a muscle plug napkin ring technique for closure of small skull base defects, wherein a free muscle graft slightly bigger than the defect is packed tightly in the defect, half extracranially and half intracranially and sealed with fibrin glue. The technique is illustrated in the case of a 58-year-old woman with a large left medial sphenoid wing/clinoidal meningioma. CONCLUSIONS: The muscle plug napkin ring technique is a simple solution to small skull base defects.

A new minimal-invasive approach for total hip replacement in sheep.

BACKGROUND: Over the last 50 years arthroplasty became the gold-standard treatment for disabling conditions of the coxofemoral joint. Variations of anterior, lateral, and dorsal incision have been applied, but as each approach requires the incision and reflection of various muscles to gain adequate exposure of the joint results are still controversial. OBJECTIVE: The purpose of this study was to develop a minimal-invasive, tissue-sparing approach in sheep with reduced risks in animal testing. METHODS: 12 mature sheep underwent hip surgery as part of a study to evaluate a hip resurfacing system. In line with the preliminary cadaveric tests a modified, minimal-invasive, musclepreserving surgical approach was sought after. RESULTS: We developed a surgical approach to the coxofemoral joint in sheep using only blunt tissue dissection after skin incision without any limitations in joint exposure or increased blood loss/duration of surgery. CONCLUSION: Even though limitations occur and femoral orientation in sheep differs from man, joint forces have similar relative directions to the bone with similar bony and vascular anatomy. Therefore, this minimal-invasive muscle preserving approach might be a safe and comparable alternative in still inevitable animal testing.

A muscle-preserving, spinous process-splitting approach for ossification of the ligamentum flavum in the thoracic spine in professional athletes: a report of three cases.

A muscle-preserving, spinous process-splitting approach may be a less invasive approach to conventional laminectomy in patients with thoracic ossification of the ligamentum flavum. Few reports have discussed the usefulness of this procedure for thoracic lesions in professional athletes who need highly active thoracic spinal function after surgery. The treatment of thoracic ossification of the ligamentum flavum using a spinous process-splitting approach in 3 professional athletes is presented. In all three cases the patients could return to play within 3 months after surgery without complications, and in two of the cases, there was no spinal deformity or local recurrence of ossification of the ligamentum flavum at the final follow-up at least 8 years after surgery. The spinous process-splitting approach could be a safe procedure for multi-level and all other forms of ossification of the ligamentum flavum and is less invasive to the paraspinal muscles, relieves back symptoms, and restores function for athletes.

Sensory Innervation of the Upper Eyelid and Its Implication for Upper Eyelid Surgery.

PURPOSE: Sensory alterations of the upper eyelid skin and eyelashes are frequently encountered after upper eyelid surgery. The objective of this study was to provide information on the exact course and distribution of sensory nerve fibers through the anatomic planes in the upper eyelid. METHODS: Ten formalin-fixed hemifaces were dissected. The nerve branches of the ophthalmic nerve in the upper eyelid were traced in an anterograde fashion. RESULTS: A total of 151 nerve fibers were recorded during dissection. The infratrochlear, supratrochlear, supraorbital, and lacrimal nerve contributed each to both the upper eyelid skin innervation and the upper eyelid rim plexus in different distribution patterns. The mean distance from the eyelid margin at which nerve fibers pierced from preseptal into the orbicularis muscle was 14 ± 1.1 mm for nerve fibers targeting the eyelid dermis and 3.7 ± 1.2 mm for nerve fibers targeting the eyelid rim plexus ( p < 0.001). The mean intraorbicular course of nerve fibers was 3 mm (0-17; standard deviation 4.1). The mean distance from the eyelid margin at which nerve fibers pierced from the orbicularis muscle into the preorbicular plane was 10 ± 1 mm for nerve fibers innervating the eyelid dermis and 1.3 ± 0.8 mm for nerve fibers innervating the eyelid rim plexus ( p < 0.001). The mean distance of the preorbicular course of nerve fibers was 2 mm (0-15; standard deviation 3.6). CONCLUSIONS: Based on the findings, a certain degree of postoperative eyelid skin numbness is inevitable while eyelash innervation may be spared in upper blepharoplasty.

Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis.

BACKGROUND: The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and undercorrection. This article describes the authors' extended frontalis muscle advancement technique, which takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis. METHODS: A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1, levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, and cosmetic result was performed at the last follow-up. RESULTS: From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative margin reflex distance 1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0%) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7%) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2%) had an excellent or good cosmetic result. CONCLUSIONS: Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, and minimizes undercorrection, residual lagophthalmos, eyelid contour abnormality, and eyebrow ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.