Topical therapy for regression and melanoma prevention of congenital giant nevi.

Giant congenital melanocytic nevi are NRAS-driven proliferations that may cover up to 80% of the body surface. Their most dangerous consequence is progression to melanoma. This risk often triggers preemptive extensive surgical excisions in childhood, producing severe lifelong challenges. We have presented preclinical models, including multiple genetically engineered mice and xenografted human lesions, which enabled testing locally applied pharmacologic agents to avoid surgery. The murine models permitted the identification of proliferative versus senescent nevus phases and treatments targeting both. These nevi recapitulated the histologic and molecular features of human giant congenital nevi, including the risk of melanoma transformation. Cutaneously delivered MEK, PI3K, and c-KIT inhibitors or proinflammatory squaric acid dibutylester (SADBE) achieved major regressions. SADBE triggered innate immunity that ablated detectable nevocytes, fully prevented melanoma, and regressed human giant nevus xenografts. These findings reveal nevus mechanistic vulnerabilities and suggest opportunities for topical interventions that may alter the therapeutic options for children with congenital giant nevi.

A Personal Approach to Bilateral Cleft Lip Repair.

Dr Michael B. Lewis has been using his personal approach to bilateral cleft lip (BCL) repair for 30 years to achieve a loose, pouting upper lip, a 90-degree columellar-labial angle, and a projecting nasal tip. This article describes technique and results.

Body Image After Mastectomy Scale: A New Measure of Body Image Behaviors and Beliefs in Women Following Mastectomy.

Background: Body image distress is frequently reported by women after mastectomy and is associated with negative health outcomes, such as reduced quality of life, elevated depression and anxiety symptoms, and impaired sexual functioning. To reduce body image distress after mastectomy, we must first understand the factors that contribute to its development and maintenance. We therefore developed a new measure, the Body Image after Mastectomy Scale (BIMS), to comprehensively assess maladaptive appearance-related beliefs and behaviors (e.g., avoidance and rituals) that may trigger and maintain body image distress after mastectomy. Materials and Methods: Forty-seven female patients undergoing mastectomy with breast reconstruction completed the BIMS and other measures 3 months after breast reconstruction. Results: Evaluation of the BIMS' initial psychometric properties showed that the overall scale has good internal consistency and strong construct validity. Domain-specific subscales ranged in reliability from good to poor. Conclusions: The BIMS can be used clinically to identify cognitive and behavioral psychotherapy targets to reduce body image distress resulting from mastectomy. It can also be used in research to identify factors that contribute to the development and maintenance of body image distress after mastectomy. ClinicalTrials.gov identifier: NCT03428399.

Prospective examination of psychological risk and maintenance factors for body image distress after mastectomy with immediate breast reconstruction.

Reconstructive breast surgery aims to improve body image following mastectomy, yet many women experience ongoing body image distress (BID). The relationship between the esthetic outcome of reconstructive surgery with BID has been underexplored in mastectomy. This study aimed to assess whether reconstruction outcome following mastectomy is associated with post-surgery BID, and to examine potential psychological risk and maintenance factors for BID above reconstruction outcome. In 49 women undergoing mastectomy with immediate breast reconstruction, we prospectively assessed hypothesized pre-surgery psychological risk factors and post-surgery maintenance factors for post-surgery BID. Reconstruction outcome was assessed via blind surgeon ratings of post-surgery photographs. Surgeon-rated reconstruction outcome was uncorrelated with BID, or with patients' ratings of surgical outcome. Higher pre-surgery depressive symptoms and lower pre-surgery patient expectations for reconstruction predicted greater post-surgery BID, above reconstruction outcome. Post-surgery body checking also predicted greater BID, above reconstruction outcome. Results suggest that the medical team cannot assume their perception of reconstruction outcome matches the patient's view or degree of BID. If replicated, results point to potential psychological risk and maintenance factors that are stronger predictors of post-reconstruction BID, highlighting opportunities for light-touch prevention and intervention to reduce BID after mastectomy with breast reconstruction.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes. SUMMARY: Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache.

BACKGROUND: Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies. METHODS: One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data. RESULTS: The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups. CONCLUSIONS: The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.

Patient Pain Sketches Can Predict Surgical Outcomes in Trigger-Site Deactivation Surgery for Headaches.

BACKGROUND: Patient selection for headache surgery is an important variable to ensure successful outcomes. In the authors' experience, a valuable method to visualize pain/trigger sites is to ask patients to draw their pain. The authors have found that there are pathognomonic pain patterns for each site, and typically do not operate on patients with atypical pain sketches, as they believe such patients are poor surgical candidates. However, a small subset of these atypical patients undergo surgery based on other strong clinical findings. In this study, the authors attempt to quantify this clinical experience. METHODS: Patients were prospectively enrolled and completed pain sketches at screening. One hundred six diagrams were analyzed/categorized by two independent, blinded reviewers as follows: (1) typical (pain over nerve distribution, expected radiation); (2) intermediate (pain over nerve distribution, atypical radiation); or (3) atypical (pain outside of normal nerve distribution, atypical radiation). Preoperative and postoperative Migraine Headache Index was compared between subgroups using unpaired t tests. RESULTS: Migraine Headache Index improvement was 73 ± 38 percent in the typical group, 78 ± 30 percent in the intermediate group, and 30 ± 40 percent in the atypical group. There was a significant difference in Migraine Headache Index between the typical and atypical groups (p = 0.03) and between the intermediate and atypical groups (p < 0.01). The chance of achieving Migraine Headache Index improvement greater than 30 percent in the atypical group was 20 percent. CONCLUSIONS: Patient pain sketches classified as atypical (facial pain, atypical pain point origin, diffuse pain) can predict poor outcomes in headache surgery. As the authors continue to develop patient selection criteria for headache surgery, patient sketches should be considered as an effective, cheap, and simple-to-interpret tool for selecting candidates for surgery.

Surgical management of failed colon interposition.

BACKGROUND: Complications following colon interposition may be acute or chronic and often devastating. Creative strategies are needed to preserve the conduit or develop alternatives when the conduit cannot be salvaged. METHODS: The records of patients undergoing revision surgery of colon interposition between 1965 and 2005 were reviewed. RESULTS: Thirty-five patients underwent 48 operative revisions. Nineteen patients underwent one operation, nine required multiple operations to manage one problem and seven developed more than one distinct problem requiring several operative interventions. The most common indications for revision surgery were redundancy (n=13), stricture (n=11), and loss of intestinal continuity (n=8). The most common revisional operations were anastomotic revision (n=13), segmental colonic resection (n=6), and stricturoplasty (n=4). Swallowing function was restored in 32 of 35 patients. Loss of intestinal continuity was successfully reversed in six of seven patients. There were no intraoperative deaths. Four patients required re-operation after a failed revision at our institution. Swallowing was restored in three of four patients. CONCLUSIONS: Complications that develop after colon bypass present major challenges for surgeons to maintain swallowing and quality of life. We present successful strategies to manage these devastating complications. It is the largest report dealing with a wide variety of complications of colon bypass.

Surgical Treatment of Migraine Headache: Back to the Future.

Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.

Ability to Cope with Pain Puts Migraine Surgery Patients in Perspective.

BACKGROUND: Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients' pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome. METHODS: Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison. RESULTS: All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome. CONCLUSIONS: The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Use of CO2 Fractional Photothermolysis for the Treatment of Burn Scars.

A recent advancement in the treatment of burn scars has been the use of the carbon dioxide (CO2) laser to perform fractional photothermolysis. In this analysis, we describe our results and patient-reported outcomes with the use of fractional CO2 laser for the treatment of burn-related scarring. We performed a retrospective study of all patients who underwent CO2 laser procedures for treatment of symptomatic burn scars and skin grafts at one accredited regional burn center. Burn injury and laser treatment demographics, as well as complications, are reported. A questionnaire was administered to all patients and included patient-reported outcome measures aimed at understanding the patient experience and their subjective response to treatment. A total of 387 CO2 laser procedures were performed on 131 patients for the treatment of symptomatic burn scars and skin grafts between October 1, 2011, and May 1, 2014 (average, 2.95 procedures/patient; range, 1-11). Average time between injury and first laser was 597.35 days (range, 60-13,475). Average time between laser treatments (when multiple) was 117.73 days (range, 22-514). There were no infections requiring treatment with oral antibiotics. Overall patient satisfaction with laser therapy was 96.7%. Patients reported reductions in neuropathic pain, tightness (contracture), and pruritus (54.0, 50.6, and 49.0%, respectively). Fractional photothermolysis utilizing the CO2 laser is a safe and effective modality for the treatment of symptomatic burn scars, donor sites, and skin grafts. Patient satisfaction with this procedure is high, and complications are low. Significant improvements in scar appearance, pliability, tightness, neuropathic pain, and pruritus were commonly reported.