Hirayama Disease: Surgical Restoration of Hand Function.

PURPOSE: Hirayama disease (HD) is a rare, nonfamilial, self-limiting, progressive lower cervical myelopathy, resulting in debilitating distal upper-extremity motor deficits, mimicking high ulnar neuropathy, lower trunk brachial plexopathy, or C8-T1 radiculopathy. Although most literature focuses on pathophysiology and prevention of disease progression, there remains limited discussion regarding treatment to improve upper-extremity function in patients with stable disease. The upper-extremity manifestations of HD are reviewed along with surgical options for restoring hand function. METHODS: A retrospective review of patients with HD who underwent reconstruction to improve hand function was undertaken. Demographic data, preoperative electrodiagnostic and electromyographic, and physical examination findings were collected. Outcome data involved postoperative grip, pinch, and functional assessment documented on clinical visits. Qualitative descriptions of the surgical techniques are described. RESULTS: Among six patients identified, four met the inclusion criteria and underwent tendon transfers and selected joint arthrodeses. All patients were diagnosed as teenagers, were right hand-dominant, and three were male. Unilateral symptoms were present in one patient and were bilateral in the rest. All patients were treated with tendon transfers for thumb opposition, grasp, anticlaw, and thumb interphalangeal joint arthrodesis. All patients had postoperative grip strength improvement. The average follow-up was 3.2 years. CONCLUSIONS: Hirayama disease is a rare disease often managed by spine surgeons and neurologists who may be unaware of options for restoring hand function deficits. Technical strategies and outcomes of improving hand function in HD have not been adequately described. Surgical options to improve hand function are tailored to the deficits and include tendon transfers, select joint arthrodeses, and/or tenodeses. Risk of disease progression and expectations following hand reconstruction must be managed carefully. TYPE OF STUDY LEVEL OF EVIDENCE: Therapeutic V.

Mastectomy and Chest Masculinization in Transmasculine Minors: A Case Series and Analysis by Ethical Principles.

ABSTRACT: Mastectomy for chest masculinization is a commonly performed gender-affirming surgery in minor patients, a vulnerable population with unique developmental and psychosocial needs. We aimed to use principles of medical ethics (eg, autonomy, beneficence, nonmaleficence, and justice) as a framework to analyze preoperative clinical decision making by pediatric plastic surgeons who work with transmasculine and nonbinary adolescents designated female at birth presenting for chest masculinization. Two patients were selected for inclusion in this case series based on the senior author's (J.F.C.) clinical experience. A retrospective chart review was conducted to extract relevant psychosocial and clinical information from clinic notes and supplemental documentation (eg, letters from outside providers) available in the electronic medical record. In case A, a 17-year-old patient presented to a plastic surgery clinic with mixed parental support and restrictive insurance requirements. In case B, a 16-year-old patient presented to the emergency room after an attempt to remove his own breasts. The cases highlight the role of the plastic surgeon in advocating for adolescent autonomy and justice by facilitating shared family decision making and navigating barriers to care. In addition, we recommend multidisciplinary care, including trusted, transcompetent mental health professionals, to ensure beneficence and nonmaleficence by providing timely care when appropriate.

Plastic Surgery Across Continents: A Comparison of Residency Training in Subsaharan Africa and the United States.

ABSTRACT: There is a demonstrated need for access to plastic surgical care in low- and middle-income countries worldwide. Recently, there is increasing interest in promoting transcontinental partnerships between academic institutions to improve training opportunities for local surgeons while increasing access to care for patients. Before such programs can be established, it is crucial for US-based surgeons and educators to understand the existing training models in different countries. The aim of this study is to identify the current plastic surgery training model in the College of Surgeons of East, Central, and Southern Africa (COSECSA) group of African nations and compare this to training in the United States. The curricula of 2 accrediting bodies of plastic surgery, COSECSA and the Accreditation Council for Graduate Medical Education of the United States, were compared. Similarities included the length of dedicated plastic surgery training, curriculum content, and final evaluation structure. Differences include training pathways, assessment methodology, and regulation regarding specific competencies, program requirements, and resident benefits. These findings establish a baseline understanding of how plastic surgical training is organized, delivered, and evaluated in Africa, highlight opportunities for educational initiatives, and serve as a foundation for future efforts to develop collaborative partnerships in these communities. Future research will include a survey sent to program directors and plastic surgery attendings in the COSECSA regions to gather additional information.

The Use of Botulinum Toxin to Prevent Anastomotic Thrombosis and Promote Flap Survival: A Bridge to Developing Clinical Studies.

BACKGROUND: Despite the possibility of using botulinum toxin to improve perfusion and prevent vasospasm, only a few studies have examined the use of botulinum toxin in the setting of flap surgery and thrombosis, and the mechanisms have not been fully explained. OBJECTIVE: The primary objective of this study was to provide a comprehensive review of the effectiveness of botulinum toxin in anastomotic thrombosis prevention and surgical flap survival to determine the value of conducting large-scale human trials. METHODS: Using the SYRCLE and CAMRADES criteria, a systematic review was performed. PubMed, Medline, EmBase, and the Cochrane Library were searched for studies that met our eligibility criteria. RESULTS: Twenty studies were included in the final selection. A total of 397 subjects were included. Eighteen studies used botulinum toxin type A alone, one used botulinum toxin type B alone, and only one used both botulinum toxin type A and botulinum toxin type B. The most commonly used injection technique was a preoperative intradermal injection. The most common procedure performed was a pedicled flap with random pattern skin flaps (65%). The mean injection dose was 28.17 ± 49.21 IU, whereas the mean reported injection time for studies using animal models was 7.4 ± 6.84 days. CONCLUSIONS: Similar mechanisms demonstrated in animal models may be replicable in humans, allowing botulinum toxin to be used to prolong flap survival. However, many factors, such as optimal injection techniques, dosages, and long-term outcomes of botulinum use in flap surgery, need to be further assessed before applying this to clinical practice.

Posterior Cranial Vault Distraction (PCVD): Common Complication Rates and Strategies of Prevention and Management.

BACKGROUND: Posterior cranial vault distraction (PCVD) is a well-established procedure to treat infants with craniosynostosis. Craniofacial surgeons have seen an evolution in the complications following PCVD. This report aims to demonstrate the rates of common complications from PCVD, and to identify strategies for prevention and management of these complications. METHODS: A formal literature review of studies on postoperative complications from PCVD was conducted to identify the breadth of reported complications from PCVD and rates of occurrence. RESULTS: A total of 776 articles were captured by our search strategy. Nineteen original articles met inclusion criteria, with a total of 342 patients. The average rate of reported complications was 25%, range (0%-100%). The most commonly reported complication was postoperative infection (23.7%), followed by cerebrospinal fluid leak (20.3%) and device failure (15.3%). Postoperative infection, device exposure, iatrogenic vascular injury, cerebrospinal fluid leak, and other complications have the potential to disrupt distraction and increase morbidity and mortality. CONCLUSIONS: By continuing to identify and evaluate complications, prevention strategies can be determined and standardized to decrease complications from PCVD. These efforts uphold the ultimate goal for surgeons involved in the treatment of craniosynostosis: to provide safe, effective surgical care.

Influence of Self-Perceived Vulvar Appearance on Female Sexual Function.

BACKGROUND: Female sexual function is a complex model of biological and nonbiological factors. The impact of self-perceived vulvar appearance on female sexual function is not well understood. OBJECTIVES: The aim of this study was to determine the influence of vulvar appearance on sexual function in adult women. The primary aim was to assess the relation between self-perceived vulvar appearance and sexual function. The secondary aim was to assess the influence of prior genital procedures on vulvar appearance and sexual function. METHODS: An observational study of adult women was conducted utilizing Amazon Mechanical Turk, an online crowdsourcing platform. The survey instrument included demographic information, subjective vulvar appearance measures, and the Female Sexual Function Index (FSFI) questionnaire. RESULTS: Out of 398 respondents, 148 (37.2%) reported concern about their vulvar appearance and 134 (33.7%) reported a history of genital cosmetic procedures. Women who were uncomfortable with their vulvar appearance had lower FSFI scores than those comfortable with their vulvar appearance, 24.6 vs 27.0 (P = 0.01), respectively. Among women uncomfortable with their vulvar appearance, 70.9% of subjects met the criteria for sexual dysfunction. Women who were uncomfortable with their vulvar appearance were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.43; 95% CI: 1.46-4.10; P < 0.001). Women with a history of cosmetic genital procedures were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.46; 95% CI: 1.43-4.23). CONCLUSIONS: Women who are uncomfortable with their vulvar appearance had higher rates of sexual dysfunction. Women seeking cosmetic genital procedures should be screened for sexual dysfunction to facilitate realistic expectations and optimal care.

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis.

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.

Atypical Fibroxanthoma in a 13-Year-Old Guatemalan Girl with Xeroderma Pigmentosum.

Xeroderma pigmentosum (XP) is a rare, autosomal recessive disease involving a defect in DNA repair leading to the premature development of numerous aggressive cutaneous malignancies. Although atypical fibroxanthoma (AFX) is a neoplasm typically found in the setting of extensive sun exposure or therapeutic radiation, AFXs are rarely associated with children with XP. We report the case of a 13-year-old Guatemalan girl with the XP type C variant who developed one of the largest AFXs reported on a child's finger.

Short-Scar Mammaplasty in Severe Macromastia.

It is generally claimed that short-scar mammaplasty is limited to small-to-medium reductions. Its use in patients with severe macromastia has been associated with a high rate of complications. This report presents our experience of reduction mammaplasty greater than 1000 g per breast using a short-scar technique. The procedure is based on the following: a) modified breast marking method with conservative placement of the nipple-areola complex, determined not only by the level of the inframammary fold but also degree of upper pole volume loss; b) use of liposuction for contouring the inferior pole; c) vertical design dermoglandular resection; d) superomedial pedicle; and e) skin closure without undermining or gathering. A total of 69 patients were identified (n = 138 breasts). Mean age was 38.0 years with average BMI of 36.4 kg/m. Mean weight of breast removed was 1333.8 g (range, 1002-3275). New nipple position was determined to be inferior to the inframammary fold at a mean distance of 4.6 cm, as predicted by the degree of flatness of upper pole. Complications included delayed healing (7.2%), fat necrosis (10.1%), infection (5.8%), hematoma (2.9%), and seroma (1.5%). There were no instances of nipple-areola complex necrosis. Revision of dog-ears was necessary in 7 patients (10.1%). The authors conclude that in using a modified short-scar mammaplasty approach in cases of severe macromastia, the outcomes can be improved with reduced scar burden, pleasing breast shape, and a low complication rate.

Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand.

A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.

How Should Surgeons Consider Emerging Innovations in Artificial Intelligence and Robotics?

Artificial intelligence (AI)-assisted robotic surgery seems to offer promise for improving patients' outcomes and innovating surgical care. This commentary on a hypothetical case considers ethical questions that AI-facilitated surgical robotics pose for patient safety, patient autonomy, confidentiality and privacy, informed consent, and surgical training. This commentary also offers strategies for mitigating risk in surgical innovation.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review.

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery.

The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program. Methods: Data on operative repair of flexor tendon lacerations from 2006 to 2014 were reviewed and compared with those from 2015 to 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine. Results: In total, 780 patients with flexor tendon laceration injuries were included. Mean patient age was 38 years; mean time between tendon injury and first evaluation was 4 days, and the mean time from injury to operative repair was 12 days. Four-strand sutures remain the most common technique of tendon repair (57%). In the recent cohort, there were significant decreases in tourniquet use (94% versus 89%), general anesthesia (88% versus 74%), and monofilament sutures (44% versus 35%), with a significant increase reported in preserving the A1 pulley (20% versus 29%). Postoperative movement was described as "almost full range of motion" or "good" in 70% of cases, and 74% of patients were satisfied with their results. Postoperative adverse events were reported in 26% of cases, with the most common complications being tendon adhesions (14%) and rupture (3%). Conclusions: Review of The American Board of Plastic Surgery tracer data for operative repair of flexor tendon lacerations establishes a framework by which surgeons can evaluate how their current practice aligns with that of their peers, and whether their practice patterns remain current relative to recommendations from evidence-based medicine.

"Post Mastectomy Pain Syndrome: A Systematic Review of Prevention Modalities".

BACKGROUND: Post-mastectomy pain syndrome (PMPS) is a surgical complication of breast surgery characterized by chronic neuropathic pain. The development of PMPS is multifactorial and research on its prevention is limited. The objective of this systematic review is to synthesize the existing evidence on interventions for lowering the incidence of persistent neuropathic pain after breast surgery. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search of the electronic databases of MEDLINE, Cochrane Library, Embase, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov using a combination of database-specific controlled vocabulary and keyword searches. Two reviewers independently screened all unique records. Publications on chronic (>3-month duration) pain after breast cancer-related surgery were included. Studies were classified by modality. RESULTS: Our literature search yielded 7092 articles after deduplication. We identified 45 studies that met final inclusion criteria for analysis, including 37 randomized-controlled trials. These studies revealed seven major intervention modalities for prevention of PMPS: physical therapy, mindfulness-based cognitive therapy, oral medications, surgical intervention, anesthesia, nerve blocks, and topical medication therapy. CONCLUSION: High-quality data on preventative techniques for PMPS are required to inform decisions for breast cancer survivors. We present a comprehensive assessment of the modalities available that can help guide breast and reconstructive surgeons employ effective strategies to lower the incidence and severity of PMPS. Our review supports the use of multimodal care involving both a peripherally targeted treatment and centrally acting medication to prevent the development of PMPS.

Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report.

CASE: A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION: Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.

The Role of Plastic Surgeons in Female Genital Mutilation Reconstructive Surgery.

The World Health Organization defines female genital mutilation (FGM) as any procedure involving partial or total removal of female external genitalia or other injury to genital organs for non-medical indications. Despite prohibitory legislation in the United States and significant morbidity related to FGM procedures, the practice continues throughout the globe with three million women at risk annually. Surgical care for women with FGM has historically been in the hands of obstetrician and Gynaecologists (OB GYNs), and mainly focused to help safe labor and delivery. Recent awareness of the need for improved reconstructive surgical care for FGM has developed in the plastic surgical literature. This Current Opinion article highlights the historical surgical care for FGM and the opportunity for plastic surgeons to get more involved in the multidisciplinary care of these patients.

Kiteboarding Induced Abdominal Wall Pain: Intercostal Neuroma versus Anterior Cutaneous Nerve Entrapment (ACNES).

Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can have similar presentations. Anterior cutaneous nerve entrapment syndrome has been reported to be a significant cause of AWP. Here, we report the case of a patient who was initially diagnosed with anterior cutaneous nerve entrapment syndrome and ultimately found to have intercostal neuromas-in-continuity. The patient was a healthy 36-year-old man who presented with debilitating, chronic abdominal wall pain. The pain began after a time period when the patient was regularly kiteboarding, and it impacted the ability to exercise and perform activities of daily living. The patient had undergone extensive testing and attempted many treatments, including medication, nerve blocks, and anterior cutaneous nerve entrapment syndrome surgery. Examination was significant for 2 near-symmetric areas that were persistently tender to palpation in the subcostal abdomen. The patient underwent excision and reconstruction with two 2-cm segments of processed nerve allograft. At 1-year follow-up, the patient reported complete alleviation of the pain, discontinuation of pain medication, and a return to all normal activities. While managing patients with abdominal wall pain, physicians must consider neuroma in their differential diagnoses and be aware of its treatment options, as the patient underwent a substantial delay in treatment. Kiteboarding is a unique mechanism of peripheral nerve injury that has not been previously reported in the literature. This report demonstrates the efficacy of processed nerve allograft in the management of neuromas-in-continuity of the abdominal wall, as well as the importance of being aware of unusual manners of nerve injury.

Surgical Treatment of Abdominal Wall Neuromas.

Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature. METHODS: All patients who underwent surgical treatment for painful abdominal wall neuromas by the senior author at Northwestern Memorial Hospital were reviewed. Patients were treated with neuroma excision and allograft nerve reconstruction and/or with targeted muscle reinnervation (TMR). Follow-up pain surveys were issued to assess pain levels, activities of daily living, and pain medication usage. RESULTS: Twenty patients met inclusion criteria. Eighteen (90%) patients reported improvement in neuropathic pain postoperatively. Two (10%) patients had TMR following failed nerve allograft reconstruction, which led to complete pain resolution. Twenty-seven nerves were treated surgically, the majority of which were abdominal intercostal (13), followed by ilioinguinal (10), genitofemoral (3), and iliohypogastric (1). Nerve allograft reconstruction was used alone for 18 procedures, in combination with TMR for 2, and TMR was used alone in 8. In all cases of TMR, the freshened nerve ending after neuroma excision was coapted to a motor nerve of the internal oblique. The mean length of follow-up was 18.9 months (SD ±14.5). CONCLUSIONS: This retrospective review demonstrated that 90% (18) of the patients had significant improvement in abdominal neuroma pain postoperatively. These results may help guide providers toward effective management of abdominal wall neuropathic pain.

Representation of Ethics in the Plastic Surgery Literature: A Systematic Review.

BACKGROUND: A 2009 systematic review demonstrated that ethical discourse was underrepresented in the plastic surgery literature; approximately one in 1000 articles contained ethical discussions. In the decade since, advances in plastic surgery and continued social progress have created new ethical dilemmas. However, it is unclear whether these developments have augmented the representation of ethics in the plastic surgery literature. A review of publications over the past decade can assess whether progress has been made and identify where deficits persist. METHODS: The authors searched eight bibliographic databases to identify peer-reviewed articles discussing ethical issues in plastic surgery over the past decade. Independent reviewers extracted characteristics and ethical principles from included articles. RESULTS: A total of 7097 articles were identified from the initial search and 531 articles were included for analysis. The principle of autonomy, present in 87.9 percent of articles, had the greatest representation, followed by beneficence (74.4 percent), nonmaleficence (72.3 percent), and justice (51.2 percent). Informed consent and face transplantation were the most prevalent topics discussed. Aesthetic surgery was the subdiscipline of plastic surgery with the greatest ethical discourse, representing 29.8 percent of all included articles. CONCLUSIONS: In the past decade, there was approximately a five-fold increase in plastic surgery publications that include ethical discourse, indicating a growing awareness of ethical implications by the plastic surgery community. However, representation of ethical principles remained uneven, and specific subdisciplines of plastic surgery were substantially underrepresented. Plastic surgeons should adopt a more comprehensive approach when framing ethical implications in clinical and research settings.

Surgical management of female genital mutilation-related morbidity: A scoping review.

BACKGROUND: Over 200 million women and girls worldwide have suffered from the partial to total removal of external female genitalia for nonmedical purposes, referred to as female genital mutilation (FGM). Survivors of FGM may develop debilitating physical and psychological long-term sequelae. This is the first study to examine the scope of the extant surgical literature on the management of FGM-related morbidity. METHODS: A systematic scoping review of five major research citation databases was conducted. RESULTS: A total of 190 articles from 29 countries met the inclusion criteria. The majority (76%) were primary source articles and from obstetrics and gynecology literature (71%). Reported interventions for FGM-related morbidity were defibulation, cyst excision, clitoral and vulvar reconstruction, urological reconstruction, peripartum procedures, labial adhesion release, and reinfibulation. CONCLUSIONS: Surgery for FGM complications spans multiple specialties, which suggests multidisciplinary collaboration benefit. Plastic and reconstructive surgeons have a clear role in the multidisciplinary care team for these patients. This scoping review identified a paucity of high-quality evidence with respect to functional quality of life outcomes and long-term follow-up.