Combined Distal Interphalangeal Joint Arthrodesis With Proximal Interphalangeal Joint Arthroplasty or Arthrodesis: Technical Considerations.

Combined distal interphalangeal joint (DIP) arthrodesis with proximal interphalangeal joint (PIP) arthroplasty or arthrodesis presents unique challenges. Although less common than isolated surgery for the DIP and PIP joints, with an aging population, combined DIP and PIP procedures are an increasingly encountered occurrence. Anatomical and morphological studies have provided length and width measurement standards for the middle and distal phalanges, allowing for planning to assess the compatibility of strategies. Besides reviewing anatomical studies to provide length and width guidelines for hardware placement, we will also discuss optimal hardware combinations for combined surgical intervention in the DIP and PIP joints. Conflict may exist between hardware used for the DIP arthrodesis and implants used for the PIP arthroplasty. As an example, if K-wires are used for DIP arthrodesis, any intervention in the PIP joint will be compatible. However, if headless screws are used for DIP arthrodesis, these should ideally not reach proximal to the midpoint of the middle phalanx. Other techniques, such as single or multiple oblique screws, and tension bands are compatible with PIP arthroplasty. Hence, options for management of the PIP joint are dependent on the technique used for DIP arthrodesis.

UK Trainee Experience with WALANT - An Audit of 102 Cases.

Background: WALANT has gained much popularity in recent years, especially with COVID-19. However, a recent survey of the American Society for Surgery of the Hand membership (i.e. attendings/consultants) showed that only 17% were exposed to WALANT during residency or fellowship training. There is much interest in WALANT from trainees, but interpretation of the type and volume to be administered is highly varied. Methods: The aims of this study were (1) to survey a group of plastic surgery trainees in the UK about their knowledge of WALANT formulas, and (2) to compare trainee logbook records of WALANT procedures (if available) with published data from the UK. Results: All trainees were familiar with the 'standard' WALANT formula (1% lidocaine, 1:100,000 adrenaline ± 8.4% NaHCO3) described by Lalonde. However, because of local formularies, rather than 1:100,000 adrenaline, all used 1:200,000 adrenaline as it comes premixed in the UK. Other formulas used by UK trainees included 0.5% bupivacaine + 1:200,000 adrenaline, and mixing 1% lidocaine + 1:200,000 adrenaline with 1% lidocaine 1:1. In comparing available trainee WALANT records with published UK data, the average volume of WALANT used was 6.6 mls in the current study versus 12.9 mls for similar procedures (wound debridement and skin closure ± local flap, digital nerve repair, fingertip reconstruction, thenar injuries, phalangeal fracture and single digit extensor repair); specifically, for single digit flexor tendon repairs, this was 10 mls versus 16.3 mls. Conclusions: While the British Society for Surgery of the Hand (BSSH) have developed official guidance for the use of WALANT in the UK, it appears there remains much variation in interpretation and hence, application. Comparison of trainee logbook records of common hand surgery procedures suggests that most can be done with much less WALANT administered than previously reported, with safe and reproducible results. Level of Evidence: Level IV (Therapeutic).

Conventional High-Dose vs Low-Dose Hyaluronidase for Skin Necrosis after Hyaluronic Acid Fillers: A Systematic Review and Pilot Meta-Analysis.

BACKGROUND: Hyaluronidase remains the mainstay treatment for skin necrosis due to vascular occlusion after hyaluronic acid (HA) dermal fillers. There is wide variability in protocols for the administration of hyaluronidase. Most protocols, however, lack strong evidence regarding hyaluronidase dosages. METHODS: We conducted a systematic review and pilot meta-analysis, searching four international databases from inception until December 2023 for clinical studies reporting on two or more patients receiving hyaluronidase for skin necrosis after hyaluronic acid fillers. Random-effects (DerSimonian and Laird) meta-analyses were conducted. The primary outcome was the pooled proportion of complete scar resolution. We rated intra-study risk of bias using the Joanna Briggs Institute checklists and assessed the certainty of evidence using the GRADE approach. RESULTS: We included 15 studies totaling 223 patients. The pooled proportion of complete scar resolution after hyaluronidase administration was 77.8% (95%-CI: 65.5% to 86.6%, pegger = 0.093, low certainty). Patients treated with high doses of hyaluronidase (>500 international units [IUs]) had lower rates of resolution of 69.6% (95%-CI: 41.2% to 88.3%) compared to those treated with low doses (500IU or less) that had 88.1% rate of resolution (95%-CI: 86.0% to 96.2%), though not statistically significant (p= 0.18). The use of adjunct therapies did not have a statistically significant effect on outcomes. CONCLUSION: A higher proportion of patients receiving low doses (500IU or less) (88.1%) had complete scar resolution compared to patients receiving high doses (69.7%), though not statistically significant (p=0.18). Future studies should provide more granular details on their protocols to benefit the formulation of evidence-based guidelines in future. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . PROTOCOL REGISTRATION: CRD42024538661.

Surgical Treatment of Lymphedema in the Upper Extremity.

The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.

Alternative Flap Options for Upper Extremity Reconstruction.

For major upper limb defects, a wide range of established pedicled and free flap options can be used. These include the latissimus dorsi/thoracodorsal artery perforator, lateral arm, posterior interosseous artery, rectus abdominis, gracilis, and anterolateral thigh flaps. Technical proficiency is essential, and favorable success rates in terms of functional and esthetic outcomes can be achieved. Herein, alternative flap options (both pedicled and free) are introduced and discussed through a few illustrative case examples.

Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study.

PURPOSE: Gender affirmation in trans men requires multiple staged procedures. The final masculinizing step involves phalloplasty or metoidioplasty and further incorporation of penile and testicular prostheses. However, these are functionally suboptimal and associated with high complication rates. Therefore, we sought to investigate the anatomical feasibility of one-stage genitourinary vascularized composite allotransplantation (GUVCA) for such gender-affirming surgeries. METHODS: Twenty fresh cadaveric dissections were performed to delineate the neurovascular anatomy of the proposed GUVCA. Specifically, in donors (n = 14), besides the penis and scrotum, the GUVCA included an inferior bladder patch with the urinary sphincter, prostate, seminal vesicles, as well as a strip of the pubic bone. In trans men recipients, osteotomies of the pubic bone to match that of the donor GUVCA were required. Five cadaveric GUVCA transplants were then performed to simulate one-stage gender affirmation surgery. RESULTS: The GUVCA required (1) vascular anastomoses between the recipient's deep inferior epigastric, external pudendal, and superficial circumflex iliac (or superficial inferior epigastric) vessels to the donor's internal pudendal, external pudendal and genitofemoral vessels respectively; (2) neurosynthesis between the recipient pudendal and dorsal clitoral nerves to the donor pudendal and genitofemoral nerves; and (3) urinary bladder anastomosis at the bladder neck, upstream of the urinary sphincter. Average donor measurements (length (cm), diameter (mm)) were: external pudendal artery (2.5, 2.0) and vein (2.0, 3.5), internal pudendal artery (15.0, 4.0), pudendal (15.0, 3.0) and genitofemoral nerves (8.0, 2.0). CONCLUSIONS: We have described the anatomical basis for a one-stage GUVCA in trans masculine genitourinary reconstruction.

Lower Limb Serratia marcescens Necrotizing Fasciitis Complicated by Nosocomial COVID-19.

Serratia marcescens represents an unusual yet potentially deadly cause of lower limb necrotizing fasciitis (NF). Compounding the already high mortality of NF, S. marcescens infections are usually associated with worse outcomes (i.e., amputation). Here we present the case of a 56-year-old immunocompromised man due to lupus nephritis who developed lower limb NF secondary to S. marcescens followed by nosocomial coronavirus disease 2019 (COVID-19) pneumonitis. Successful limb salvage was achieved through a multidisciplinary team approach from various specialties including plastic surgery, orthopedic surgery, anesthesiology, intensive care, respiratory medicine, and nephrology. At 11 months' follow-up, the patient was largely independent with activities of daily living and was able to ambulate. Unfortunately, he suffered a myocardial infarction at 19 months post-operatively and passed away. A review of the literature revealed only a handful of cases of lower limb NF due to S. marcescens and none with subsequent COVID-19. Therefore, this is the first report of such a case which should help with the clinical management of such cases going forward, especially with COVID-19 now becoming endemic in our communities and contributing to delayed presentations and increased mortality in NF.

The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction.

Background and Objective: The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction. Methods: A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included "DIEP flap" and "deep inferior epigastric perforator flap". Key Contents and Findings: A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction. Conclusions: The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Single-Institution Early Experience With a New, Smooth, Opaque, and Round Breast Implant Over a 2-Year Period.

Background: The ideal breast implant does not exist and the choice of implant for breast augmentation is largely based on what surgeons think will be best for their patients. Objectives: To evaluate the preliminary results of a new, smooth, round, and opaque breast implant (PERLE, GC Aesthetics; Dublin, Ireland) from a single-center UK aesthetic practice. Methods: Retrospective cohort study of all patients undergoing breast implant surgery with PERLE at the authors' center between January 2021 and December 2022. Outcomes data such as rates of capsular contracture, infection, revision surgery, and synchronous mastopexy were analyzed. Results: Of the 385 patients identified, 374 (97.1%) had PERLE implants placed by 3 surgeons for primary (n = 290) and secondary breast augmentation (n = 21), and augmentation-mastopexy (n = 63). Capsular contracture occurred in no cases, infection in 1 (0.2%), and revision surgery in 21 patients (5%). The incision used was always submammary, unless a synchronous mastopexy was performed; implants were placed in the subglandular/subfascial plane in the majority of cases (85.3%), and the rest were dual plane (14.7%). Eight revisions were performed in patients undergoing breast augmentation (due to implant displacement in 6 patients, and hematoma and infection in 1 patient each). Fourteen revisions were performed in those undergoing augmentation-mastopexy. The average follow-up time was 18 months. Conclusions: The authors' early, single-center experience with PERLE implants suggests a safety profile and overall complication rate that is comparable with other modern implants. They will continue to monitor the safety and effectiveness of PERLE and discuss the reasons and evolution in the choice of breast implant.

Tolerance of a Vascularized Composite Allograft Achieved in MHC Class-I-mismatch Swine via Mixed Chimerism.

Background: Vascularized composite allografts (VCAs) allow reconstruction of devastating injuries and amputations, yet require lifelong immunosuppression that is associated with significant morbidity. Induction of immune tolerance of VCAs would permit widespread use of these procedures. VCAs are acquired from deceased donors most likely to be fully-MHC-mismatched (in contrast to living-related renal transplant donor-recipient pairs matched at one MHC haplotype). After achieving VCA tolerance in a swine model equivalent to clinical living-related renal transplants (single-haplotype MHC mismatches: e.g., "mother-daughter"/haploidentical), we tested our protocol in MHC class I, class II, and fully-MHC-mismatched pairs. Although class II mismatched swine demonstrated similar results as the haploidentical scenario (stable mixed chimerism and tolerance), our protocol failed to prevent rejection of class I and full mismatch VCAs. Here, we describe a new adapted conditioning protocol that successfully achieved tolerance across MHC class-I-mismatch barriers in swine. Methods: Swine were treated with non-myeloablative total body and thymic irradiation two days prior to infusion of bone marrow cells from an MHC class I-mismatched donor. They also received a short-term treatment with CTLA4-Ig (Belatacept®) and anti-IL6R mAb (Tociluzimab®) and were transplanted with an osteomyocutaneous VCA from the same donor. Results: Stable mixed chimerism and tolerance of MHC class-I-mismatched VCAs was achieved in 3 recipients. Allograft tolerance was associated with a sustained lack of anti-donor T cell response and a concomitant expansion of double negative CD4-CD8- T cells producing IL-10. Conclusions: This study demonstrates the first successful mixed chimerism-induced VCA tolerance in a large animal model across a MHC class-I-mismatch. Future studies aimed at fully-mismatched donor-recipient pairs are under investigation with this protocol.

Use of Micro Botulinum Toxin for a Face-lifting Effect: A Systematic Review.

BACKGROUND: Micro-Botox (Micro-btx) was described in 2000 for the paralysis of superficial muscle fibers to address facial rhytides. Increasingly, there are reports of its off-label use for a face-lifting effect. OBJECTIVE: To evaluate the literature for such results. METHODS AND METHODS: A systematic review was performed according to PRISMA; only Level ≥ III evidence from 2000 to 2020 were included. Data extracted include patient demographics, type of botulinum toxin, dilution, dosage, injection sites and spacing, needle size and syringe, follow-up, patient and physician assessment, and complications. RESULTS: Three hundred seventy-two patients (average 35.2 years) underwent different botulinum toxin injections (average 39 units/hemiface) of varying dilutions with 30- to 32-G needles, typically with 1-mL syringes, by forming 0.2- to 0.5-cm wheals 1 cm apart. Follow-up averaged 10.5 weeks with both subjective and objective assessments. Facial asymmetry and minor bruising were common. Subjective assessment of face-lifting effects between patients and physicians was highly discordant and injection sites reported were highly variable. CONCLUSION: Much heterogeneity in dosage, injection sites, definition of "face-lifting," and assessment methods remain, all of which preclude accurate and objective evaluation of the current evidence for micro-btx. Future studies should address these variables, given the growing interest in such nonsurgical options for a face-lifting effect.

Local FK506 implants in non-human primates to prevent early acute rejection in vascularized composite allografts.

BACKGROUND: Previous vascularized composite allograft (VCA) studies from our laboratory have shown that topical FK506 delivery in non-human primates (NHPs) was limited by inadequate dermal penetration and rejection persisted. Herein, we report the first utilization of FK506 via subcutaneously implanted discs to mitigate VCA rejection in NHPs. METHODS: Full major histocompatibility complex (MHC)-mismatched NHP pairs underwent partial-face VCA and FK506 disc implantation along the suture line. All allotransplants were maintained post-operatively for two months on the FK506 discs, methylprednisolone, mycophenolate mofetil, and supplemented with intramuscular FK506 if necessary. Group 1 (n=4) was used for optimization of the implant, while Group 2 (n=3) underwent delayed bone marrow transplantation (DBMT) after two months. VCA skin biopsies and peripheral blood samples were obtained for serial assessment of rejection and mixed chimerism by histopathology and flow cytometry respectively. RESULTS: In Group 1, two technical failures occurred. Of the remaining two NHPs, one developed supratherapeutic levels of FK506 (50-120 ng/mL) and had to be euthanized on postoperative day (POD) 12. Reformulation of the implant resulted in stable FK506 levels (20-30 ng/mL) up to POD12 when further intramuscular (IM) FK506 injections were necessitated. In Group 2, two NHPs survived to undergo conditioning and one successfully developed chimerism at 2-3 weeks post-DBMT (96-97% granulocytes and 7-11% lymphocytes of recipient-origin). However, all three NHPs had to be terminated from study at POD64, 77 and 86 due to underlying post-transplant lymphoproliferative disorder. All VCAs remained rejection-free up to study endpoint otherwise. CONCLUSIONS: This study shows preliminary results of local FK506 implants in potentially mitigating VCA acute rejection for tolerance protocols based on mixed chimerism approach.

The Perception of Plastic Surgery by Community-Based, Private Practice Nurses: A French National Descriptive Study.

Plastic surgery is a dynamic field but remains poorly understood by general practitioners, medical students, health professionals, and the public. The main health care professionals in the community who are involved in the follow-up of plastic surgery patients are nurses; they help to facilitate wound healing and rehabilitation in the postoperative period. In this study, the authors assessed the medical knowledge and perceptions of plastic surgery by nurses working in the community setting and explored their understanding of classical scenarios commonly encountered in reconstructive surgery. An online survey was designed to assess the demographics of nurses working in the community in France and their knowledge of plastic surgery. This was disseminated to all practicing nurses working outside of hospitals by means of an online social network from the period of April 2019 to June 2019. The survey was completed by 318 nurses. Specific training in plastic surgical nursing will be required to optimize the management of these patients following discharge from hospital. This gap in knowledge may affect patient recovery negatively.