Surgical Management of Chronic Neuropathic Burn Pain.

Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.

High-Density Porous Polyethylene Implant Cranioplasty: A Systematic Review of Outcomes.

Porous polyethylene has been widely used in craniofacial reconstruction due to its biomechanical properties and ease of handling. The objective of this study was to perform a systematic review of the literature to summarize outcomes utilizing high-density porous polyethylene (HDPP) implants in cranioplasty. A literature search of PubMed, Cochrane Library, and Scopus databases was conducted to identify original studies with HDPP cranioplasty from inception to March 2023. Non-English articles, commentaries, absent indications or outcomes, and nonclinical studies were excluded. Data on patient demographics, indications, defect size and location, outcomes, and patient satisfaction were extracted. Summary statistics were calculated using weighted averages based on the available reported data. A total of 1089 patients involving 1104 cranioplasty procedures with HDPP were identified. Patients' mean age was 44.0 years (range 2 to 83 y). The mean follow-up duration was 32.0 months (range 2 wk to 8 y). Two studies comprising 17 patients (1.6%) included only pediatric patients. Alloplastic cranioplasty was required after treatment of cerebrovascular diseases (50.9%), tumor excision (32.0%), trauma (11.4%), trigeminal neuralgia/epilepsy (3.4%), and others such as abscesses/cysts (1.4%). The size of the defect ranged from 3 to 340 cm 2 . An overall postoperative complication rate of 2.3% was identified, especially in patients who had previously undergone surgery at the same site. When data were available, contour improvement and high patient satisfaction were reported in 98.8% and 98.3% of the patients. HDPP implants exhibit favorable outcomes for reconstruction of skull defects. Higher complication rates may be anticipated in secondary cranioplasty cases.

Evaluation of predictive factors of septic wrist to avoid overdiagnosis.

BACKGROUND: The existing diagnostic criteria for septic wrist are nonspecific, exposing patients with noninfectious etiologies to surgical morbidity. This study aimed to identify predictors differentiating septic wrist from other etiologies. METHODS: An institutional review board-approved retrospective review was conducted on patients with a presumed diagnosis of septic wrist (2003-2022). Bivariate and multiple regression analyses were performed to identify correlation between confirmed septic wrist and comorbidities (autoimmune diseases, immunosuppression, crystalline arthropathy, intravenous [IV] drug use, smoking), penetrating trauma, fever, multi-joint involvement, inflammatory markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]/white blood cells [WBC]), serum uric acid level, blood cultures, imaging findings, and synovial fluid analysis. Categorical data were reported as median [interquartile range]. RESULTS: Hundred and sixty-eight (58 females and 110 males) patients were included. The median length of hospitalization and follow-up were 6[7] days and 1[3] months. Eighty-nine (53%) patients had septic wrist confirmed with Gram stain/culture, 48 (29%) patients received alternative diagnoses, and 31 (18%) patients had undetermined diagnoses. Concomitant septic wrist and crystalline arthropathy were identified in 9 patients (6.6% of total patients). Out of the 48 patients who received alternative diagnoses, 12 (25%) underwent open drainage. Elevated synovial WBC count (95,409.4 ± 85,926.2) showed a trend of association with septic wrist (p = 0.08). Negative synovial crystals (p = 0.01), positive blood culture (p = 0.04), negative history of crystalline arthropathy (p = 0.08), and multi-joint involvement (p = 0.05) were identified as predictors of septic wrist with a combined sensitivity of 87.5%, specificity of 86.2%, and area under the curve 0.93. CONCLUSIONS: Current diagnostic criteria for septic wrist have low specificity. Negative history of crystalline arthropathy, multi-joint involvement, absence of synovial crystals, and positive blood culture are helpful indicators for predicting septic wrist in patients presenting with a painful, erythematous, and swollen wrist.

Management of Acute Carpal Tunnel Syndrome: A Systematic Review.

Purpose: This review aims to compare recovery outcomes of conservative, early operative, and a combination of conservative and operative management for acute carpal tunnel syndrome (ACTS). Methods: A literature search of PubMed, Scopus, and CINAHL from 1970 to 2022 was conducted using the keywords carpal tunnel syndrome and acute nerve compression. ACTS was defined as a case within 12 weeks of symptom onset. Primary data extracted included causes (traumatic or atraumatic), symptom duration (<1 day, 1-7 days, or 8-84 days), intervention (surgical, conservative, or conservative then surgical), follow-up duration, and outcome (full recovery or non-full recovery). Logistic regression analyses and χ2 tests were performed to investigate associations among these variables. Results: A total of 197 patients involving 127 (64.5%) traumatic and 70 (35.3%) atraumatic cases were included. Forty-seven percent of patients were managed conservatively followed by surgery, 30% conservative only, and 23% surgery only. The traumatic group was associated with better recovery than the atraumatic group. Recovery outcomes were not associated with symptom duration or follow-up time. The choice of intervention was not associated with traumatic or atraumatic etiology, nor did it affect recovery outcomes in either group. Conclusions: Traumatic ACTS is associated with better recovery outcomes than atraumatic etiologies. Surgical intervention was not found to be associated with better outcomes than conservative management, regardless of the etiologies. Further prospective studies are warranted to compare surgical versus conservative management. Clinical Relevance: Currently, there are no guidelines for the best management of ACTS, and it is not known if early or delayed surgical treatment is optimal. This review compiles the current evidence and identifies gaps in the literature, highlighting the need for further investigation to provide the best clinical practice.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review.

BACKGROUND: Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty. METHODS: A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables. RESULTS: A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03). CONCLUSIONS: Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

The Potential Role of Exosomes in Aesthetic Plastic Surgery: A Review of Current Literature.

Despite an increasing surge of exosome use throughout the aesthetic arena, a paucity of published exosome-based literature exists. Exosomes are membrane-bound extracellular vesicles derived from various cell types, exerting effects via intercellular communication and regulation of several signaling pathways. The purpose of this review was to summarize published articles elucidating mechanisms and potential applications, report available products and clinical techniques, and prompt further investigation of this emerging treatment within the plastic surgery community. Methods: A literature review was performed using PubMed with keywords exosomes, secretomes, extracellular vesicles, plastic surgery, skin rejuvenation, scar revision, hair growth, body contouring, and breast augmentation. Publications from 2010 to 2021 were analyzed for relevance and level of evidence. A Google search identified exosome distributors, where manufacturing/procurement details, price, efficacy, and clinical indications for use were obtained by direct contact and summarized in table format. Results: Exosomes are currently derived from bone marrow, placental, adipose, and umbilical cord tissue. Laboratory-based exosome studies demonstrate enhanced outcomes in skin rejuvenation, scar revision, hair restoration, and fat graft survival on the macro and micro levels. Clinical studies are limited to anecdotal results. Prices vary considerably from $60 to nearly $5000 based on company, source tissue, and exosome concentration. No exosome-based products are currently Food and Drug Administration-approved. Conclusions: Administered alone or as an adjunct, current reports show promise in several areas of aesthetic plastic surgery. However, ongoing investigation is warranted to further delineate concentration, application, safety profile, and overall outcome efficacy.

Comparing the educational quality of free flap technique videos on public and paid platforms.

BACKGROUND: Surgical videos are reshaping the landscape for surgical education. As this form of education has rapidly grown and become a valuable resource for experienced surgeons, residents, and students, there is great variability in the presentation of what is offered. This study aimed to assess and compare the educational quality of free flap instructional videos on public and paid platforms. METHODS: Free flap videos from public (YouTube) and paid (American Society of Plastic Surgeons Education Network and Plastic and Reconstructive Surgery Journal) sources were screened independently by three reviewers. Sample size was calculated to reach 80% power. The educational quality of the videos was determined using a modified version of Laparoscopic Surgery Video Educational Guidelines (0-6 low, 7-12 medium, 13-18 high). Professionally-made videos were identified per lighting, positioning, and video/imaging quality. Interrater reliability between the three reviewers was calculated. The educational quality of the videos was compared between public and paid sources using Mood's median test. Pearson's correlation coefficient was utilized to assess the correlation between video length and educational quality. RESULTS: Seventy-six videos were included (40 public, 36 paid). The median video lengths for public and paid platforms were 9.43(IQR = 12.33) and 5.07(IQR = 6.4) min, respectively. There were 18 high, 16 medium, and 6 low-quality public videos, versus 13 high, 21 medium, and 2 low-quality paid videos. Four public and seven paid videos were identified as professionally made. Interrater reliability was high (α = .9). No differences in educational quality were identified between public and paid platforms. Video length was not correlated with quality (p = .15). A video library compiling public high-quality videos was created (https://www.youtube.com/playlist?list=PL-d5BBgQF75VWSkbvEq6mfYI--9579oPK). CONCLUSIONS: Public and paid platforms may provide similar surgical education on free tissue transfer. Therefore, whether to subscribe to a paid video platform for supplemental free flap education should be determined on an individual basis.