Dissecting Cellulitis of the Scalp: A Review and Case Studies of Surgical Reconstruction.

Dissecting cellulitis of the scalp (DCS) is a part of the follicular occlusion tetrad (hidradenitis, acne conglobata, and pilonidal disease). It is a spectrum disorder that can be severe and refractory to medical management. The authors describe 3 such cases successfully treated with surgical resection and reconstruction and present a scoring system for timely referral of such patients to a reconstructive surgical team. METHODS: A literature review of all available cases of DCS was undertaken, and the treatments and outcomes were reviewed. Our institution has had 3 recent cases that demonstrated delayed presentation common in the severe spectrum of this condition. All underwent radical surgical resection and reconstruction with skin grafting that was very positively received by all the patients. RESULTS: Three cases of DCS were treated with radical scalpectomy, and split-thickness skin grafting was done with a good cosmetic outcome and a high degree of subjective patient satisfaction. All would have received timely referral if the presented scoring system had been applied earlier. CONCLUSIONS: DCS is a rare but debilitating condition that may progress to a medically refractory condition requiring surgical intervention. Surgical resection and skin grafting offer a durable cure, but delayed presentations are common. Use of a scoring system may reduce the time to surgical referral for refractory cases.

All hands on deck: Hand replantation versus transplantation.

OBJECTIVES: Our hands play a remarkable role in our activities of daily living and the make-up of our identities. In the United States, an estimated 41,000 individuals live with upper limb loss. Our expanding experience in limb transplantation-including operative techniques, rehabilitation, and expected outcomes-has often been based on our past experience with replantation. Here, we undertake a systematic review of replantation with transplantation in an attempt to better understand the determinants of outcome for each and to provide a summary of the data to this point. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted PubMed searches from 1964 to 2013 for articles in English. In total, 53 primary and secondary source articles were found to involve surgical repair (either replantation or transplantation) for complete amputations at the wrist and forearm levels. All were read and analyzed. RESULTS: Hand replantations and transplantations were compared with respect to pre-operative considerations, surgical techniques, post-operative considerations and outcomes, including motor, sensation, cosmesis, patient satisfaction/quality of life, adverse events/side effects, financial costs, and overall function. While comparison of data is limited by heterogeneity, these data support our belief that good outcomes depend on patient expectations and commitment. CONCLUSION: When possible, hand replantation remains the primary option after acute amputation. However, when replantation fails or is not possible, hand transplantation appears to provide at least equal outcomes. Patient commitment, realistic expectations, and physician competence must coincide to achieve the best possible outcomes for both hand replantation and transplantation.

Pacinian hyperplasia presenting with Raynaud's phenomenon.

Pacinian corpuscle pathology is a rare clinical entity and an uncommonly reported cause of digital pain. While many prior reports implicate hand trauma, we describe a case of Pacinian hyperplasia found in a patient with Raynaud's phenomenon and propose a potential mechanism of disease.

Upper Antero-Medial Thigh as an Alternative Site for Implantation of Intrathecal Pumps: A Case Series.

INTRODUCTION: Neuraxial drug delivery via intrathecal drug delivery systems (IDDS) is becoming an increasingly common mode of treating intractable cancer-related pain, chronic pain, or severe spasticity. An implanted infusion pump delivers medication into the intrathecal (subarachnoid) space via a thin catheter. These pumps are commonly placed in the anterior abdominal wall. Certain conditions may render it difficult or unsafe for an IDDS to be implanted at the traditional site; thus, alternative sites have been explored. We report on the use of the upper antero-medial thigh as a safe alternative site for this purpose. METHODS AND MATERIALS: Nine patients between 22 and 69 years of age underwent placement of an IDDS infusion pump in the upper antero-medial aspect of one thigh. In each patient, the anterior abdominal wall was precluded for implantation due to various reasons, such as extensive abdominal scar tissue from previous surgeries, placement of feeding tubes and ostomies, large ventral hernia or metastatic masses protruding from the abdomen. RESULTS: Nine patients, with ages ranging from 22 to 69 years old, had IDDS implantation in the upper thigh. The first patient experienced wound dehiscence (antero-lateral location) and after explantation, another pump was placed successfully in the opposite thigh (antero-medial location). One patient has had pump replacement due to end-of-battery life. She also needed an unrelated catheter revision. Seven patients have expired from their disease progression after living for an average of 142.7 days (range 50 days to 354 days) while two patients continue to experience relief from pain and spasticity years later (see Table 1). No neurovascular damage, infections, or other complications occurred in our series. CONCLUSION: The upper antero-medial thigh is a safe alternative to the anterior abdominal wall for implantation of an IDDS.

Rehabilitation following hand transplantation.

BACKGROUND: Hand allotransplantation can restore motor, sensory and cosmetic functions to upper extremity amputees. Over 70 hand transplant operations have been performed worldwide, but there is little published regarding post-hand transplant rehabilitation. METHODS: The Brigham and Women's Hospital (BWH) Hand Transplantation Team's post-hand transplant rehabilitation protocol is presented here. The protocol must be modified to address each transplant recipient's unique needs. It builds on universally used modalities of hand rehabilitation such as splinting, edema and scar management, range of motion exercises, activities of daily living training, electrical stimulation, cognitive training and strengthening. RESULTS: The BWH hand transplant rehabilitation protocol consists of four phases with distinct goals, frequency, and modalities. (1) Pre-operative: functional assessments are completed and goals and expectations of transplantation are established. (2) Initial post-operative (post-operative weeks 1-2): hand protection, minimization of swelling, education, and discharge. (3) Intermediate (post-operative weeks 2-8): therapy aims to prevent and/or decrease scar adhesion, increase tensile strength, flexibility and function, and prevent joint contractures. (4) Late (from 8 weeks forward): maximization of function and strength, and transition to routine activities. The frequency of rehabilitation therapy decreases gradually from the initial to late phases. CONCLUSIONS: Rehabilitation therapy after hand transplantation follows a progressive increase in activity in parallel with wound healing and nerve regeneration. Careful documentation of progress and outcomes is essential to demonstrate the utility of interventions and to optimize therapy protocols.

Why we are here: early reflections on the role of reconstructive plastic surgery in the 2013 Boston marathon bombings.

The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.

Three patients with full facial transplantation.

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction.

BACKGROUND: The reverse sural fasciocutaneous flap provides the potential for simple and efficient closure of distal leg, ankle, and foot defects. In young patients with traumatic injuries, low complication rates have been reported. The authors hypothesize that extending its use to older patients with comorbidities results in a higher complication rate. METHODS: The authors retrospectively reviewed 58 consecutive reverse sural fasciocutaneous flap in 57 patients for distal leg reconstruction. Outcomes were compared between patients with no comorbidities (n = 31) and those with a history of smoking, diabetes mellitus, or peripheral arterial disease (n = 26). Standard statistical analyses were performed, including logistic regression. RESULTS: Patients had a mean age of 53 years and a median follow-up of 20 months. Fifty percent of flaps had postoperative complications, with nine (16 percent) major complications (three total flap losses and six partial losses), 17 (29 percent) minor complications, and three infections. In patients without comorbidities, there were no major complications and five minor complications (16 percent). Significantly higher major and minor complication rates were seen in older patients and patients with a history of smoking, obesity, diabetes, or peripheral arterial disease. Multivariate regression analysis identified smoking as the risk factor most independently associated with any reverse sural fasciocutaneous flap complication. Importantly, surgical delay procedures were associated with decreased ischemic flap complications in patients with comorbidities. CONCLUSIONS: Although the reverse sural fasciocutaneous flap is reliable in young healthy patients, it has significant complication rates in patients with comorbidities, especially smokers. In such patients, the reverse sural fasciocutaneous flap requires multiple operative revisions and a surgical delay should be considered.

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child.

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.