Review of Gender Affirming Mastectomy Surgery: Comparing Drains Versus No Drains.

BACKGROUND: Gender-affirming mastectomy can improve mental health and gender expression. However, there is no consensus on routine drain usage in gender-affirming surgeries. The purpose of this study is to compare gender-affirming mastectomies with and without drains and review complications. METHODS: An institutional review board-approved, retrospective review was performed to identify patients between 2017-2021 who had double-incision mastectomy, with or without nipple graft, and separated into drain and no-drain cohorts. Patient demographics, outcomes, and postoperative complications were analyzed, including unplanned return to the operating room, seromas, hematomas, postoperative infection, and postoperative antibiotic use. Univariate and multivariate analysis was performed. RESULTS: There were 359 patients that had a gender-affirming mastectomy surgery between 2017 and 2021. The mean age was 26.1 years old, and mean body mass index was 27.4. There were 144 patients (40.1%) who had a drain, and 215 patients (59.9%) without a drain. For postoperative complications of all patients, there were 12 (3.3%) unplanned returns to the operating room, 18 seromas (5.0%), 26 hematomas (7.2%), 50 (13.9%) postoperative antibiotic use, and 4 postoperative infections (1.1%). There were no significant differences found between drain use for all postoperative complications, but no-drain use was significantly associated with less prescribed postoperative antibiotics compared to drain use (3.7% and 29.0%, respectively; P < 0.001). CONCLUSIONS: Gender-affirming mastectomy surgeries are safe and effective treatment options. No-drain placement was not associated with increased postoperative complications. Surgeons may consider not prescribing routine postoperative antibiotics if using drains, and avoiding drains for gender-affirming mastectomies may be considered in selected individuals based on clinical judgment.

Nonrheumatoid Arthritis of the Hand.

Arthropathy of the hand is commonly encountered. Contributing factors such as aging, trauma, and systemic illness all may have a role in the evolution of this pathology. Besides rheumatoid arthritis, other diseases affect the small joints of the hand. A review of nonrheumatoid hand arthropathies is beneficial for clinicians to recognize these problems.

Spindle Cell Lipoma of the Neck: Review of the Literature and Case Report.

Spindle cell lipomas (SCL) are benign, slow growing tumors arising most frequently in the subcutaneous tissue of the upper back, posterior neck, and shoulders in males aged 40-70 years. Local excision is generally curative. Classification of lipomatous tumors has progressed recently, and tumors of similar morphology and unusual presentation are increasingly reported, thereby making correct diagnosis even more vital. SCL require pathologic differentiation from liposarcoma, other spindle cell neoplasms, and myxoid lesions for treatment purposes. Cytology, histology, and cytogenetics, in conjunction with clinical presentation, are paramount in arriving at the correct diagnosis of spindle cell lipoma. We present a case report with characteristics typical of an SCL along with a literature review to further elucidate the diagnosis and surgical treatment of this soft tissue tumor.

C7 nerve root sensory distribution in peripheral nerves: a bold functional magnetic resonance imaging investigation at 9.4 T.

INTRODUCTION: In this study we used a rat model to elucidate the linear make-up of each major nerve of the upper limb by the C7 root through sensory stimulation and functional magnetic resonance imaging (fMRI). METHODS: The C7 nerve root and major nerves of the right forelimb were stimulated electrically. Blood oxygen level-dependent functional magnetic resonance imaging (BOLD fMRI) was performed concurrently. Voxel overlap within the primary sensory cortex was calculated. RESULTS: C7 comprised sensation in <1% in the musculocutaneous nerve, 6% in the ulnar nerve, 16% in the radial nerve, and 19% in the median nerve (P<0.005 for each). The overlap was always <25% for each major nerve. CONCLUSIONS: This study helps explain why C7 is a suitable donor for brachial plexus injury treatment and why there is only a transient sensory deficit after transfer.

Cortical plasticity induced by different degrees of peripheral nerve injuries: a rat functional magnetic resonance imaging study under 9.4 Tesla.

BACKGROUND: Major peripheral nerve injuries not only result in local deficits but may also cause distal atrophy of target muscles or permanent loss of sensation. Likewise, these injuries have been shown to instigate long-lasting central cortical reorganization. METHODS: Cortical plasticity changes induced after various types of major peripheral nerve injury using an electrical stimulation technique to the rat upper extremity and functional magnetic resonance imaging (fMRI) were examined. Studies were completed out immediately after injury (acute stage) and at two weeks (subacute stage) to evaluate time affect on plasticity. RESULTS: After right-side median nerve transection, cortical representation of activation of the right-side ulnar nerve expanded intra-hemispherically into the cortical region that had been occupied by the median nerve representation After unilateral transection of both median and ulnar nerves, cortical representation of activation of the radial nerve on the same side of the body also demonstrated intra-hemispheric expansion. However, simultaneous electrical stimulation of the contralateral uninjured median and ulnar nerves resulted in a representation that had expanded both intra- and inter-hemispherically into the cortical region previously occupied by the two transected nerve representations. CONCLUSIONS: After major peripheral nerve injury, an adjacent nerve, with similar function to the injured nerve, may become significantly over-activated in the cortex when stimulated. This results in intra-hemispheric cortical expansion as the only component of cortical plasticity. When all nerves responsible for a certain function are injured, the same nerves on the contralateral side of the body are affected and become significantly over-activated during a task. Both intra- and inter-hemispheric cortical expansion exist, while the latter dominates cortical plasticity.

Vastus lateralis flap reconstruction after girdlestone arthroplasty: thirteen consecutive cases and outcomes.

BACKGROUND: Pressure ulcers are found in approximately 4.7% of hospitalized populations. Up to 12.3% of hospitalized populations are at risk for developing these wounds. Decubitus ulcers are more common among the inpatient spinal cord injury group, with prevalence rates up to 30%. Surgical intervention is required when bone or the hip joint becomes involved. Girdlestone arthroplasty is a procedure that excises affected proximal femur and acetabular tissues; however, this resection typically results in a sizeable defect. The vastus lateralis flap has been extensively reviewed as a soft tissue filler option for this deficit. MATERIALS AND METHODS: Thirteen consecutive cases from a single institution using the vastus lateralis muscle flap reconstruction after Girdlestone arthroplasty were reviewed. A search of internal records identified 11 patients with 13 vastus lateralis flap reconstructions performed immediately after Girdlestone arthroplasty for stage 4 ulcers or chronic, infected wounds affecting the hip joint. All patients involved were subjected to a similar standardized post-procedure activity schedule. Complications were defined as minor (superficial wound breakdown) or major (requiring further operative procedures to close the wound). RESULTS: The majority of patients were male (91%) with a mean age of 43 years at the time of the procedure. All wounds involved the hip joint proper. Ninety-one percent of the patients had a history of spinal cord deficits. Thirty-one percent of the flaps had minor, superficial wound breakdown. Another 31% of the reconstructions required an additional operative procedure for major wound complications. One patient's wound was from multiple prior failed hip replacements. He eventually became ambulatory using a walker after reconstruction. Ultimately, 69% of the flaps healed satisfactorily without the need for further operative intervention. CONCLUSIONS: Surgical debridement is required for chronic wounds involving the proximal femur, acetabulum, and hip joint. This review demonstrates that the use of a single-stage procedure including Girdlestone arthroplasty with immediate vastus lateralis muscle flap reconstruction is a practical treatment option for chronic wounds involving the acetabular joint. The use of a postoperative protocol and subsequent sitting schedule contributed to the success of these reconstructions. Overall, this procedure is applicable to spinal cord injury/pathology patients and to failed total hip arthroplasty patients for future assisted ambulation.

The free fillet flap after traumatic amputation: a review of literature and case report.

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.

TGF-beta1 RNA interference in mouse primary dura cell culture: downstream effects on TGF receptors, FGF-2, and FGF-R1 mRNA levels.

BACKGROUND: Transforming growth factor (TGF)-beta1 and fibroblast growth factor (FGF)-2 have both been shown to have significant roles in the regulation of murine calvarial suture fusion. Methods to decrease gene expression of these cytokines and their respective receptors have been established, but because of side effects, clinical applications are limited. In this study, the authors examined the effect of TGF-beta1-specific small interfering RNA (siRNA) on the messenger RNA (mRNA) expression of TGF-beta1, its TGF-betaR1 and TGF-betaR2 receptors, and FGF-2 and its R1 receptor in murine dura cells. METHODS: A primary dura cell line was established from CD-1 mice. Transfection efficiency using Lipofectamine was determined using BLOCKiT. Dura cells were transfected with serial concentrations of TGF-beta1 siRNA to determine the optimal dose. In subsequent experiments, cells were transfected with 16 nM TGF-beta1 siRNA and harvested on posttransfection days 4, 7, 10, and 14 for RNA isolation and quantitative polymerase chain reaction. RESULTS: Optimal inhibition of TGF-beta1 mRNA expression was achieved at 16 nM siRNA. On posttransfection day 4, TGF-beta1 mRNA levels were significantly decreased but returned to baseline by day 14. TGF-betaR1 mRNA expression remained unaffected by transfection throughout the time course. However, TGF-betaR2, FGF-2, and FGF-R1 demonstrated significant inhibition of mRNA expression on posttransfection day 4. CONCLUSIONS: These results indicate that TGF-beta1 siRNA has the potential to alter the murine dura cytokines responsible for suture fusion in vitro. Manipulating underlying cranial suture biology with siRNA technology may ultimately allow control over suture fusion. This intervention may ultimately function as an effective adjunct to surgical intervention for craniosynostosis.