Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects.

BACKGROUND: Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. METHODS: A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. RESULTS: Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. CONCLUSIONS: Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Use of Tendon Allograft for Recurrent Extensor Carpi Ulnaris Instability in Ehlers-Danlos Syndrome: A Case Report.

Background Subluxation of the extensor carpi ulnaris (ECU) tendon can be a challenging problem to the surgeon, with no options described for failure following autologous reconstruction. It is our intention to provide guidance on technique by describing our experience in a 20-year-old male with Ehlers-Danlos syndrome. Case Description The patient presented with pain and snapping of the ECU tendon, and failed both immobilization and ECU reconstruction with autologous extensor retinaculum. A gracilis tendon allograft was used to reconstruct the ECU sheath, in addition to ulnar groove deepening. At 1-year follow-up, the patient had no pain and the ECU was stable without recurrent subluxation. Literature Review To the authors' knowledge, the use of tendon allograft for stabilization of recurrent ECU subluxation following surgical repair or reconstruction has not been previously described in the medical literature. Clinical Relevance Utilization of tendon allograft is a viable technique to stabilize the ECU tendon while minimizing the risk in relying on compromised autologous tissue. This report represents the first account of successful reconstruction following failed autologous reconstruction.

Rethinking Global Health Education in Plastic Surgery Residency.

Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing.

Linear Modeling to Reduce Bias in Plastic Surgery Residency Selection.

BACKGROUND: Consistently selecting successful, productive applicants from an annual candidate pool is the goal of all resident selection practices. Efforts to routinely identify high-quality applicants involve scrutiny of multiple factors and formulation of an ordinal rank list. Linear modeling offers a quantified approach to applicant selection that is strongly supported by decades of psychological research. METHODS: For the 2019 residency application process, the University of Wisconsin Plastic Surgery Residency Program used linear modeling in their evaluation and ranking process. A linear model was developed using United States Medical Licensing Examination Step 1 and Step 2 scores, letters of recommendation, publications, and extracurricular activities as inputs. RESULTS: The applicant's total score was calculated from a maximum total score of 100. The mean and median scores were 49 and 48, respectively, and applicants were ranked according to total score. A separate rank list was maintained using our program's standard methodology for applicant ranking, which involves global intuitive scoring during the interview process. The Spearman rank correlation coefficient between the two lists was 0.532, and differences between the rank lists were used as a fulcrum for discussion before making the final rank list. CONCLUSIONS: This article presents the first known instance of the use of linear modeling to improve consistency, increase fairness, and decrease bias in the plastic surgery residency selection process. Transparent sharing of methodology may be useful to other programs seeking to optimize their own ranking methodology. Furthermore, it indicates to applicants that they are being evaluated based on fair, quantifiable criteria.

Reconstruction of Full Thickness Calvarial Defect With Dermal Regeneration Template and Full Thickness Skin Graft After Encephaloduroarteriosynangiosis.

Full-thickness defects of the calvarium often present reconstructive challenges, necessitating large rotational flaps or microsurgical free tissue transfer. Although the vascularity of the scalp is robust, there is an increased risk of wound healing complications after both direct and indirect intracranial revascularization procedures as compared to routine craniotomies, as these procedures utilize extracranial scalp vasculature to supply the ischemic brain. Patients presenting with wound healing complications following intracranial revascularization surgeries may not be candidates for extensive reconstructive procedures, as they are often medically comorbid with cardiac disease, diabetes, and a paucity of recipient vessels for free tissue transfer due to underlying vascular disease that prompts initial revascularization surgery. We present a case of full-thickness calvarial reconstruction using dermal regeneration template and full-thickness skin grafting to the dura in a patient with a full thickness calvarial defect due to wound breakdown and exposed hardware following indirect intracranial revascularization with encephaloduroarteriosynangiosis.

Fractures of the Carpal Bones.

Diagnosis and proper initial management of acute fractures of the carpal bones is critical because of the limited blood supply of many bones of the wrist and the role of the carpus in optimizing hand function. Pathology is correctly diagnosed by a focused history and examination. Injuries may be missed with a cursory examination and routine wrist radiographs. Together, fractures of the scaphoid and triquetrum make up nearly 90% of carpal bone fractures. Relative frequency, mechanism of injury, diagnosis, and management principles are covered for each of the bones of the wrist.

Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures.

BACKGROUND: Opioid overprescribing is a nationwide problem contributing to the current epidemic. This study evaluated opioid consumption, physician prescribing, and patient satisfaction with pain control following outpatient plastic surgery procedures. METHODS: Patients completed a questionnaire during their first postoperative visit. The authors queried about procedure type, quantity of opioids prescribed and consumed, days to opioid cessation, prescription refills, pain scores, use of nonopioid analgesics, and satisfaction with pain control. RESULTS: One hundred seventy patients were included. On average, 26 tablets were prescribed and 13 were consumed. Eighty percent of patients stopped opioids by postoperative day 5. Patients rated their worst pain at 6.1 and follow-up pain at 1.9. Approximately 50 percent of patients consumed nonopioid analgesics. Ninety-six percent of patients were satisfied with their pain control. Similar findings were observed across procedure subcategories. The number of pills prescribed was not correlated with satisfaction but was predictive of worst pain level (p = 0.014). Reduction mammaplasty and abdominoplasty patients consumed the most opioids at 17 and 18.6 pills, respectively; however, first-stage alloplastic breast reconstruction had the largest percentage of patients consuming opioids at the time of follow-up (25 percent) and requiring refills (7 percent). Patients who underwent revision of their reconstructed breast reported the earliest opioid cessation, rated their pain the lowest, and were prescribed the most excess tablets. CONCLUSIONS: Plastic surgeons are prescribing almost double the amount of opioids consumed by patients after outpatient plastic surgery procedures. The results of this study may help guide prescribing practices.

Erratum: Opioid Prescribing and Consumption Trends in Outpatient Plastic Surgery: Erratum.

[This corrects the article DOI: 10.1097/01.GOX.0000533930.73173.70.].

Rare Hypothenar Myxoma Causing Ulnar Neuropathy: Histopathology and Treatment Pearls.

A myxoma is a neoplasm comprised of mesenchymal connective tissue. Myxomas of the upper extremity, and particularly of the hand, are rare. We present a case of a hypothenar myxoma causing ulnar neuropathy in a patient with a history of acute inflammatory demyelinating process. Treatment and management of myxoma may vary depending on whether the process is malignant or benign; thus, histologic diagnosis is critical to determining treatment. The purpose of this article is to review the pathophysiology and clinical features of myxomas, and to provide recommendations for evaluating and treating individuals with extremity masses of unclear clinical diagnosis.

A Prospective Randomized Trial Comparing the Effects of Lidocaine in Breast Reduction Surgery.

BACKGROUND: Use of dilute epinephrine tumescent solution in breast reduction surgery has been shown to significantly decrease operative blood loss without increasing perioperative complications. Lidocaine is commonly added to epinephrine to decrease postoperative pain. Evidence supporting this practice, however, is limited, and lidocaine toxicity has been reported. METHODS: With institutional review board approval, patients undergoing bilateral breast reduction surgery were assigned to receive either tumescent saline solution with epinephrine (1:1 million) (group 1), or tumescent saline solution with epinephrine (1:1 million) and lidocaine (0.05%) (group 2). Tumescent solution (500 ml) was infiltrated just before skin incision. Wise pattern reduction with an inferior pedicle was used in all cases. A nurse in the postanesthesia care unit documented immediate postoperative pain and intravenous narcotic use. Patients used a survey to record postoperative pain, nausea/vomiting, and narcotic use for the first 24 hours. Results were analyzed using analysis of variance and logistic regression models. RESULTS: Forty consecutive patients were enrolled (20 in each group). There was no statistical difference between groups 1 and 2 in total intravenous narcotic use (0.89 versus 0.55; p = 0.10), 24-hour narcotic use (32.19 versus 29.47; p = 0.71), peak pain scores both in the postanesthesia care unit (5.47 versus 4.47; p = 0.24) and 24 hours postoperatively surgery (6.44 versus 6.68; p = 0.78), and 24-hour nausea/vomiting counts [group 1, OR, 1.11 (p = 0.87); group 2, OR, 1.87 (p = 0.51)]. There were no hospital admissions in either group. CONCLUSIONS: The addition of lidocaine to tumescent solution does not significantly affect postoperative pain following breast reduction surgery. Considering potential risks and added costs, this practice may not be of benefit. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.