Building a Multidisciplinary Clinic Dedicated to Upper-Extremity Limb Loss.

Complete care of the patient with upper limb loss mandates a long-term, multifaceted approach. Increased functionality and quality of life require collaborative efforts between the patient's surgeon, prosthetist, hand therapists, mental health professionals, and peers. An individual surgeon may find that initiating and maintaining a practice offering total integrated treatment for upper-extremity amputees is a formidable task, but with specific, actionable recommendations, the process can be demystified. The upper-extremity surgeon must be facile with operative techniques such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and soft tissue reconstruction and focus on team recruitment strategy and promotion of the clinic within the community. Consistent communication and team decision-making shape each patient's preoperative and postoperative course. We aim to relay effective interventions at each step of recovery from each clinic member and describe clinic workflow designed to reinforce holistic care. We present a blueprint for creating a functional and comprehensive multidisciplinary center for patients with upper-extremity limb loss for those providers interested in providing care, but who are missing the logistical roadmap for how to do so.

Same-Day Mastectomy and Immediate Prosthetic Breast Reconstruction: A 12-Year National Database Analysis and Early Postoperative Outcomes.

BACKGROUND: Coronavirus disease of 2019 and rising health care costs have incentivized shorter hospital stays after mastectomies with immediate prosthetic reconstruction. The purpose of this study was to compare postoperative outcomes following same-day and non-same-day mastectomy with immediate prosthetic reconstruction. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2019 was performed. Patients who underwent mastectomies and immediate reconstruction with tissue expanders or implants were selected and grouped based on length of stay. Univariate analysis and multivariate regression were performed to compare 30-day postoperative outcomes between length-of-stay groups. RESULTS: A total of 45,451 patients were included: 1508 had same-day surgery (SDS) and 43,942 were admitted for 1 or more night (non-SDS). There was no significant difference in overall 30-day postoperative complications between SDS and non-SDS following immediate prosthetic reconstruction. SDS was not a predictor of complications (OR, 1.1; P = 0.346), whereas tissue expander reconstruction decreased odds of morbidity compared with direct-to-implant reconstruction (OR, 0.77; P < 0.001). Among patients who had SDS, smoking was significantly associated with early complications on multivariate analysis (OR, 1.85; P = 0.010). CONCLUSIONS: This study provides an up-to-date assessment of the safety of mastectomies with immediate prosthetic breast reconstruction that captures recent advancements. Postoperative complication rates are similar between same-day discharge and at least 1-night stay, suggesting that same-day procedures may be safe for appropriately selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Standardized Perioperative Protocol and Routine Ketorolac Use for Head and Neck Free Flap Reconstruction.

No consensus exists on ideal perioperative management or anticoagulation regimen for free flap reconstruction of the head and neck. Perceived benefits from antiplatelet therapy need to be balanced against potential complications. Ketorolac, a platelet aggregation inhibitor and a parenteral analgesic, was introduced as part of a standardized perioperative protocol at our institution. In this study, we aimed to examine the impact of implementation of this protocol as well as complications associated with the routine use of perioperative ketorolac in a diverse group of patients who underwent head and neck free flap reconstruction. Methods: A single institution retrospective review was performed, including all patients who underwent head and neck free flap reconstruction between October 2016 and November 2019. Patients were divided into two cohorts: those who received ketorolac as part of a standardized protocol, and those who did not. Results: Twenty-four consecutive patients with 24 head and neck free flaps were evaluated. Eighteen patients were in the standard protocol, and six were not. There were no microvascular thromboses, flap failures, or hematomas in either group. Intensive care unit length of stay and opiate use were significantly reduced in the standardized protocol group. Conclusions: A standardized perioperative protocol for head and neck free flap reconstruction can reduce hospital and intensive care unit length of stay. No statistically significant differences in complication rates were identified when comparing ketorolac use and perioperative regimens among patients undergoing a diverse set of microsurgical head and neck free flap reconstructions.

Addition of "Septal Window" to Lower Blepharoplasty for the Management of Fat of the Lower Eyelids.

BACKGROUND: The most common reason for dissatisfaction and reoperation in lower blepharoplasty patients is persistent bulging of the lateral fat pad. This compartment contributes the most to fat herniation and yet is the most commonly overlooked. The addition of a septal window, a small opening of the septum on the most prominent part of the lateral fat compartment, helps with precise removal of lateral fat and allows for additional fat excision after septal reset without disrupting the arcuate expansion. METHODS: Our lower blepharoplasty approach includes 1) a subcilliary incision; 2) aggressive lateral fat excision through a septal window; 3) central and medial fat excision, transposition, and septal reset; 4) canthopexy; 5) orbicularis oculi muscle suspension; and 6) no dissection of orbicularis oculi medially and no skin resected medially to avoid lid retraction. We performed a retrospective review of all lower blepharoplasty cases by a single surgeon over 10 years. Demographics and operative outcomes were queried. RESULTS: There were 224 cases, 90% were women with a mean age of 58.2 years. The most common postoperative occurrences were eyelid edema, malar edema, and chemosis, all of which were self-limiting. Two patients needed additional removal of lateral fat of their lower eyelids.Two patients had lid retraction, one of which had a previous facial nerve palsy and the other did not have a canthopexy and developed transient unilateral lid retraction that resolved with conservative treatment. Resumption of full activities and exercises at 6 weeks was typical. CONCLUSION: The septal window facilitates aggressive resection of the lateral fat pad and additional fat excision after septal reset to create a smooth lid-cheek junction. In our practice, it is a critical component of a successful lower blepharoplasty.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery.

BACKGROUND: Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified. RESULTS: A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R2=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times. CONCLUSION: Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center.

PURPOSE: A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. METHODS: A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. RESULTS: Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). CONCLUSION: Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Clinical Outcomes After Neurolysis for the Treatment of Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Neurolysis techniques have been adapted for decompression of peripheral nerves in multiple locations, including the common peroneal nerve (CPN) at the fibular neck. The aim of this study was to conduct a systematic review and meta-analysis to summarize the clinical outcomes of neurolysis for the management of peroneal nerve palsy (PNP). METHODS: Preferred Reporting Systems for Systematic Reviews and Meta-Analyses guidelines were followed for this meta-analysis. Four databases were queried, and randomized clinical trials, cohort studies, case-control studies, and case series with n > 10 published in English that evaluated clinical outcomes of neurolysis for the treatment of PNP and foot drop were included. Two reviewers completed screening and data extraction. Methodological quality was evaluated using the Newcastle-Ottawa Scale. RESULTS: A total of 493 articles were identified through literature search. Title and abstract screening identified 39 studies for full-text screening. Ten articles met the inclusion criteria for qualitative analysis, and 8 had complete data for meta-analysis.Overall, there were 368 patients (370 nerves) who had neurolysis of the CPN for PNP, of which 59.2% (n = 218) were men and 40.8% (n = 150) were women. The mean age of the patients was 47.1 years (SD, 10.0 years), mean time to surgery was 9.65 months (SD, 6.3 months), and mean follow-up time was 28 months (SD, 14.0 months). The median preoperative Medical Research Council (MRC) score was 1 (IQR 0, 3), with 42.2% (n = 156) having MRC score of 0. The median postoperative MRC score was 5 (IQR 4, 5), with 53.9% (n = 199) having MRC score of 5. Complications of neurolysis of the peroneal nerve for treatment of PNP included postoperative infection (0.54%, n = 2), wound dehiscence (0.27%, n = 1), hematoma (0.54%, n = 2), bleeding (0.27%, n = 1), relapse of PNP (0.27%, n = 1), and 1 case of mortality due to sepsis. CONCLUSIONS: Our meta-analysis shows that neurolysis of the CPN is safe and improves ankle dorsiflexion strength in patients with PNP. Future studies should use a standardized method of measuring sensory outcomes, and studies of higher levels of evidence are needed to better assess the clinical outcomes of neurolysis for treatment of PNP.

Facial Fractures and Mixed Dentition - What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

INTRODUCTION: The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center. METHODS: A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed. RESULTS: A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition. CONCLUSIONS: The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

A Three-Step Technique for Optimal Nipple Position in Transgender Chest Masculinization.

BACKGROUND: The ideal position of the nipple-areola complex (NAC) in the transgender population can be a challenge to determine. OBJECTIVES: The authors sought to determine the best location and aesthetics of the female to male NAC. METHODS: Patients who underwent female to male mastectomy with free nipple grafting were included. NAC position is confirmed utilizing a vertical coordinate at the level of the 4th rib near the border of the pectoralis muscle and a horizontal coordinate determined by dividing each unilateral chest into vertical thirds from midline to anterior axillary line laterally. The NAC position is confirmed at the junction of the middle and lateral third. Symmetry is ensured bilaterally by creating a triangle and transposing it side to side; the base lies from sternal notch to inframammary fold in the midline and the apex is adjusted to the NAC. A 24-question survey utilizing a 5-point Likert scale was distributed postoperatively to assess the patient's thoughts about their chest, nipples, scar, and overall experience with the gender affirmation process. RESULTS: Thirty-one patients were included in this study. Eighteen patients responded to the postmastectomy survey, all of whom were highly satisfied with the aesthetic result postoperatively. All patients felt comfortable with their exposed chest. Nipple location was particularly highly received with 100% satisfaction rate (mean Likert score, 4.72). Nipple size and shape received a mean Likert score of 4.17 and 3.89, respectively. CONCLUSIONS: The triple confirmation technique is an easy, reproducible method to guide the surgeon in relocation of the NAC.

Human-derived Acellular Dermal Matrix Grafts for Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.

BACKGROUND: Treating diabetic foot ulcers (DFUs) requires thorough understanding of available surgical tools. OBJECTIVE: This meta-analysis compares human-derived acellular dermal matrices (H-ADMs) with standard of care (SOC) to evaluate the number of healed ulcers at 12 and 16 weeks and number of days to complete healing. As a secondary outcome, the efficacy of 3 H-ADM subtypes are studied. METHODS: Two researchers searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials for relevant titles from inception through July 2018. Inclusion criteria indicated articles be randomized controlled trials investigating the effects on neuropathic, nonischemic DFUs. RESULTS: Data from 312 DFUs in total were included in the meta-analysis. The results show H-ADMs are more effective in healing patients within a 12-week (3.14; range, 2.04-4.83) and 16-week period (2.35; range, 1.25-4.43) in comparison with SOC. Further, the mean time to complete healing was shorter in the H-ADM group (-2.31 days; range, -2.67 to -1.95 days) in comparison with SOC. Within the subgroups, 2 H-ADMs were associated with a higher likelihood of complete healing within 12 weeks when compared with SOC. The third H-ADM had a point estimate, which suggested superiority over SOC. CONCLUSIONS: This study shows H-ADMs are associated with a higher likelihood of complete healing and fewer days to complete healing within a 12-week and 16-week periods when compared with SOC. Also, the commercial products performed similarly.