InternalBrace for Intercarpal Ligament Reconstruction.

SUMMARY: Intercarpal ligament injuries such as scapholunate and lunotriquetral tears are common causes of wrist pain. There is no shortage of surgical techniques to address these injuries, nor is there a lack of literature exploring this topic. However, research progress has not led to a consensus regarding the optimal management of subacute and chronic injuries without articular wear. The senior author (K.C.C.) has performed the spectrum of reconstructive techniques, including dorsal and volar approaches, tendon weaves, ligament tenodesis procedures, reduction and association procedures, and bone-ligament-bone techniques. In the absence of convincing, consistent outcomes, the authors began investigating a novel all-dorsal reconstructive technique using the Arthrex InternalBrace system. The complexity and unpredictable outcomes associated with traditional ligament tenodesis procedures led them to adopt the all-dorsal InternalBrace technique as their primary reconstructive approach. The authors have performed more than 20 procedures with this technique since 2019. In an average tourniquet time of under 60 minutes, they are able to achieve predictable carpal stabilization, pain relief, and restoration of motion. This is the preferred reconstructive approach of the senior author.

A Scoring System That Predicts Difficult Lipoma Resection: Logistic Regression and Tenfold Cross-Validation Analysis.

INTRODUCTION: Most lipomas are readily dissected and removed. However, some cases can pose surgical difficulties. This retrospective study sought to identify clinical and radiological risk factors that predict difficult lipoma resection and can be used in a clinically useful scoring system that predicts difficulty preoperatively. METHODS: The study cohort consisted of all consecutive patients who underwent resection of pathology-confirmed lipoma during 2016-2018 at a tertiary care referral center in Tokyo, Japan. Surgical difficulty was defined as difficulty separating some/all of the tumor from the surrounding tissue by hand and inability to extract the tumor in one piece. Descriptive, univariate, and multivariate logistic regression analyses were conducted to identify predictive factors. The predictive accuracy of the scoring system that included these factors was assessed by tenfold cross-validation analysis. Receiver-operating curve (ROC) analysis was conducted to identify the optimal cutoff score for predicting surgical difficulty. RESULTS: Of the 86 cases, 36% involved surgical difficulty. Multivariate analysis showed that subfascial intramuscular location (odds ratio 42.7, 95% confidence interval 3.0-608.0), broad touching of underlying structures (46.5, 3.7-586.0), in-flowing blood vessels (9.3, 1.1-78.5), and unclear boundaries (109.0, 1.1-1110.0) significantly predicted surgical difficulty. These factors were used to construct a 0-4 point scoring system (with one point per variable). On cross-validation, the accuracy of the scoring system was 82.4% (Cohen's kappa of 0.57). ROC analysis showed that scores ≥ 2 predicted surgical difficulty with sensitivity and specificity of 55% and 98%, respectively. CONCLUSIONS: Our scoring system accurately predicted lipoma resection difficulty and may help operators prepare, thereby facilitating surgery.

Multidetector-Row Computed Tomographic Analysis of the Superficial Palmar Branch of Radial Artery Perforator Flaps.

BACKGROUND: Soft-tissue defects in the hand and digits can be effectively covered by using the free superficial palmar branch of the radial artery (SPBRA) flap, which is harvested from the radial volar wrist. Because previous anatomical studies on this flap are limited, multidetector-row computed tomographic angiography of the upper limbs was conducted to characterize the three-dimensional anatomical structure of the SPBRA and its perforators in living patients. METHODS: This retrospective anatomical study was conducted from 2014 to 2019. All data from Digital Imaging and Communications in Medicine were analyzed by using their viewer. SPBRA diameter and the location where it bifurcated from the radial artery were recorded, as were the number, location, branching patterns, and diameters of its perforators and their lengths. RESULTS: In total, 30 patients met all eligibility criteria. All had the SPBRA. The vessel bifurcated from the radial artery on average 13.2 mm proximally from the radial styloid process. The 30 patients had 40 SPBRA perforators in total. Their average SPBRA-to-dermis length was 6.43 mm. All patients had at least one direct cutaneous perforator. Nine and one also had one musculocutaneous perforator and another direct perforator, respectively. All direct cutaneous perforators were located inside a 16.4-mm-diameter circle with an origin on the scaphoid tubercle. The mean diameters of the SPBRA and its perforators were 1.12 and 0.62 mm, respectively. CONCLUSIONS: All patients had at least one reliable SPBRA perforator in the radial volar wrist. The authors' results suggest that plastic surgeons can easily and safely plan the SPBRA flap design, potentially without preoperative perforator mapping.

Older Patients and Patients with Severe Arteriosclerosis Are Less Likely to Develop Keloids and Hypertrophic Scars after Thoracic Midline Incision: A Survey-Based Analysis of 328 Cases.

BACKGROUND: Surgery is a well-known trigger of keloid and hypertrophic scarring. Sternotomy scars are subject to high skin tension, which is known to promote pathologic scarring. This suggests that sternotomies in adults are associated with high pathologic scarring rates, which aligns with the authors' anecdotal experience. However, this notion has never been examined formally. Therefore, the authors conducted a survey-based cohort study of patients who had undergone a sternotomy. METHODS: All consecutive Japanese adults (18 years of age or older) who underwent cardiovascular surgery with sternotomy in 2014 to 2017 were identified in 2019 by chart review and sent a questionnaire. Respondents formed the study cohort. The questionnaire presented randomly ordered photographs of representative mature, keloid, and hypertrophic scars and asked the patients to choose the image that best resembled their midline scar when it was particularly noticeable. The incidence of self-reported pathologic scarring (keloids and hypertrophic scars were grouped together) and the patient demographic (age and sex) and clinical characteristics (intima-media thickness of the left and right common and internal carotid arteries) that were associated with pathologic scarring were determined. RESULTS: Of the 548 patients who underwent sternotomy, 328 responded for a 60 percent response rate. The mean patient age was 67 years, and 68.0 percent were male. Of these patients, 195 (59.5 percent) reported they had a pathologic scar. Compared with patients who had a mature scar, patients who had a pathologic scar had younger mean age (65 versus 69 years; p = 0.0002) and lower intima-media thickness (0.92 versus 1.05 mm; p = 0.028). CONCLUSIONS: Sternotomy was associated with a high rate of pathologic scarring. Older age and arteriosclerosis were associated with less pathologic scarring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The History of Propeller Flaps.

Several pedicled flaps were developed by Hyakusoku at the Nippon Medical School Hospital, Tokyo, Japan, in the 1980s to treat a large number of patients with postburn contractures. In this setting, the propeller flaps were described for the first time in 1991. The term propeller was used because of the blade shape of the skin island rotating on its axis. In 1989, Koshima introduced the term perforator flaps , whereas Hallock, in 2006, applied the perforator flap concept to the propeller flap. The name perforator pedicled propeller flap followed. Propeller flap had developed to be an important operative technique and a hot topic in the field of reconstructive microsurgery, with the important contribution of Teo. In 2009, the First Tokyo Meeting on Perforator and Propeller Flaps was held, where Pignatti reported the consensus on the definition and classification of propeller flaps that was given by the advisory panel of the meeting. Further evolutions developed since then will be described in this dedicated issue of Seminars of Plastic Surgery .

Our Definition of Propeller Flaps and Their Classification.

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Imaging in Propeller Flap Surgery.

Since propeller flaps are elevated as island flaps and most often nourished by a single perforator nearby the defect, it is challenging to change the flap design intraoperatively when a reliable perforator cannot be found where expected to exist. Thus, accurate preoperative mapping of perforators is essential in the safe planning of propeller flaps. Various methods have been reported so far: (1) handheld acoustic Doppler sonography (ADS), (2) color duplex sonography (CDS), (3) perforator computed tomographic angiography (P-CTA), and (4) magnetic resonance angiography (MRA). To facilitate the preoperative perforator assessment, P-CTA is currently considered as the gold standard imaging tool in revealing the three-dimensional anatomical details of perforators precisely. Nevertheless, ADS remains the most widely used tool due to its low cost, faster learning, and ease of use despite an undesirable number of false-positive results. CDS can provide hemodynamic characteristics of the perforator and is a valid and safer alternative particularly in patients in whom ionizing radiation and/or contrast exposure should be limited. Although MRA is less accurate in detecting smaller perforators of caliber less than 1.0 mm and the intramuscular course of perforators at the present time, MRA is expected to improve in the future due to the recent developments in technology, making it as accurate as P-CTA. Moreover, it provides the advantage of being radiation-free with fewer contrast reactions.

Efficiency in Digital and Hand Replantation.

The literature on surgical techniques and recent evidence in microsurgical digital and hand replantation is reviewed. Replantation should not be done routinely without considering postoperative functional outcomes. Achieving best outcomes is related to the success of microvascular anastomosis and to adequacy of bone fixation, tendon and nerve repair, and soft-tissue coverage. Replantation surgery has become a routine procedure. However, little is known about the decision-making process for digital and hand amputation. A study comparing the outcomes of digital and hand amputations treated with replantation or revision amputation is needed. Outcome assessment includes not only function but also patient-reported outcomes.

Microsurgical Flaps in Repair and Reconstruction of the Hand.

The authors' strategy for soft-tissue coverage of the hand is presented. The concept of replacing like with like and reconstruction with similar adjacent tissue enhances functional and aesthetic outcomes. In this viewpoint, the pedicle perforator flap is an ideal flap. A decision-making algorithm to select an ideal flap for a particular hand defect is challenging, requiring experiential consideration of functional outcome, appearance, donor-site morbidity, and patient satisfaction. To assist surgeons in determining the most appropriate flap with more evidence, studies are necessary to compare the outcomes of each flap by evaluating hand function, aesthetics, donor site morbidity, and patient satisfaction.

Imaging Studies for Preoperative Planning of Perforator Flaps: An Overview.

The vascular anatomy of perforators varies between individuals; thus, accurate preoperative assessment of perforators is essential for safely planning perforator flaps. Perforator computed tomographic angiography (P-CTA) with multidetector-row computed tomography (MDCT) is one of the best available methods to precisely reveal the 3-dimensional anatomic details of perforators. The aim of this report is to describe the authors' experience using P-CTA with MDCT for detecting the perforating vessel preoperatively and a step-by-step approach to harvest perforator flaps based on this technique. This report also provides a comprehensive review of literature on other preoperative assessment tools of perforators.

Reconstruction after Anterior Chest Wall Keloid Resection Using Internal Mammary Artery Perforator Propeller Flaps.

It is difficult to completely resect huge anterior chest wall keloids and then close the wound directly. We report here our retrospective analysis of our case series of patients with such keloids who underwent reconstruction with internal mammary artery perforator (IMAP) pedicled propeller flaps and then received postoperative high-dose-rate superficial brachytherapy. METHODS: All consecutive patients with large/severe keloids on the anterior chest wall who underwent keloid resection followed by reconstruction with IMAP-pedicled propeller flaps and then high-dose-rate superficial brachytherapy in our academic hospital were identified. All cases were followed for >18 months. Donor site position, perforator pedicle, flap size, angle of flap rotation, complications, and recurrence were documented. RESULTS: There were nine men and one woman. The average age was 37.9 years. The average follow-up duration was 28.7 months. The largest flap was 16 × 4 cm. The dominant perforators of the internal mammary artery were located in the sixth (n = 2), seventh (n = 5), eighth (n = 1), and ninth (n = 2) intercostal spaces. Twelve months after surgery, patients reported marked relief from keloid-associated pain and itching, except in two patients who underwent partial keloid resection; their remaining keloids were still troublesome but after conservative therapies, including steroid ointments/plasters, the keloids gradually ameliorated. Eighteen months after surgery, there was no keloid recurrence or new development of keloids on the donor site. CONCLUSIONS: IMAP-pedicled propeller flaps transfer skin tension from the anterior chest wall to the abdomen. Our series suggests that this approach combined with radiation therapy can control keloid recurrence.

Enhanced thermopower in ZnO two-dimensional electron gas.

Control of dimensionality has proven to be an effective way to manipulate the electronic properties of materials, thereby enabling exotic quantum phenomena, such as superconductivity, quantum Hall effects, and valleytronic effects. Another example is thermoelectricity, which has been theoretically proposed to be favorably controllable by reducing the dimensionality. Here, we verify this proposal by performing a systematic study on a gate-tuned 2D electron gas (2DEG) system formed at the surface of ZnO. Combining state-of-the-art electric-double-layer transistor experiments and realistic tight-binding calculations, we show that, for a wide range of carrier densities, the 2DEG channel comprises a single subband, and its effective thickness can be reduced to [Formula: see text] 1 nm at sufficiently high gate biases. We also demonstrate that the thermoelectric performance of the 2DEG region is significantly higher than that of bulk ZnO. Our approach opens up a route to exploit the peculiar behavior of 2DEG electronic states and realize thermoelectric devices with advanced functionalities.

The Value of Multidetector Row Computed Tomography Angiography for Preoperative Planning of Freestyle Pedicled Perforator Flaps.

BACKGROUND: Because the course and territory of perforators are different in each region, careful preoperative planning to identify the proper perforators can be critical to ensure a successful dissection of a freestyle pedicled perforator flap. In this study, our first experience for preoperative perforator mapping of a freestyle pedicled perforator flap using multidetector row computed tomography (MD-CT) angiography is presented. METHODS: Twelve patients were planned to undergo various soft-tissue reconstructions with freestyle pedicled perforator flaps. They were evaluated with preoperative MD-CT angiography. The OsiriX for mac software was used to process the data obtained from MD-CT angiography. The available images from MD-CT angiography were analyzed to determine where the proper perforators were located for preoperative planning of a freestyle pedicled perforator flap. Through the MD-CT angiography, the optimal perforators were mapped and a reliable flap design could be made so that the flap was elevated more safely and perfectly to cover an adjacent soft-tissue defect. RESULTS: In all 12 patients, each flap was elevated successfully based on the perforators mapped preoperatively with MD-CT angiography. A total of 27 perforators (1-3 perforators per flap) were identified by MD-CT angiography in 12 patients and later confirmed during the flap dissection (sensitivity, 100%). CONCLUSIONS: The MD-CT angiography can be a new but very effective imaging modality for preoperative planning of a freestyle pedicled perforator flap surgery. It allows surgeons to accurately select the most appropriate perforators with the shortest intramuscular or suprafascial course preoperatively leading to safer and easier flap dissection.

CASE REPORT Total Management of a Severe Case of Systemic Keloids Associated With High Blood Pressure (Hypertension): Clinical Symptoms of Keloids May Be Aggravated by Hypertension.

INTRODUCTION: Many cases of severe keloid are associated with high blood pressure (hypertension). An analysis of 100 consecutive patients with keloid in our department in 2011 revealed that patients with multiple (>3) or large keloids (>10 cm(2)) were significantly more likely to have hypertension than patients with mild keloids (<2 or <10 cm(2)). In the present paper, a case of severe keloids associated with hypertension is described. How such patients should be treated is discussed. METHODS: This 63-year-old woman had hypertension together with severe keloids that covered her right elbow, wrist joints, and thumb and made it difficult for her to use her right hand. The contractures were released by using surgery and postoperative radiation therapy. The internal medicine clinic started her on a Ca-channel blocker (amlodipine besilate) and an angiotensin II blocker (candesartan cilexetil). RESULTS: The contractures were completely released by a distally based radial artery flap and postoperative 4 MeV electron beam irradiation (15 Gy/3 fractions for 3 days). The angiotensin-converting enzyme inhibitor and the Ca-channel blocker improved the objective symptoms of the remaining keloids. CONCLUSIONS: If patients with severe keloids present, the possibility of hypertension should be considered: the patient may have hypertension already or may be affected in the future. Hypertension may be a risk factor of keloid deterioration. Antihypertensive treatment may reduce symptoms of patients with severe keloids. At present, surgery and postoperative radiotherapy appear to be the only solution to the functional problems experienced by patients with severe keloids.

Evidence on prognosis.

In the clinical decision-making process, prognostic information gives physicians guidance regarding disease and treatment that can be passed along to patients. Using the clinical scenario of a type IIIB open tibial fracture as an example, this article focuses on how to search prognostic literature effectively and how to critically appraise prognostic studies. A well-built clinical question using the Patients, Intervention, Comparison, and Outcomes methodology helps plastic surgeons derive information from the vast resources in an effective and time-efficient manner. Subsequent critical appraisal of the collected studies is the essential step for identifying the most relevant high-quality evidence to provide the best prognostic information to guide patient decision-making.

Developing the art of scientific presentation.

PURPOSE: Few guidelines exist regarding the most effective approach to scientific oral presentations. Our purpose is to (1) develop a standardized instrument to evaluate scientific presentations based on a comprehensive review of the available literature regarding the components and organization of scientific presentations and (2) describe the optimal characteristics of scientific presentations. METHODS: At the Sixty-sixth (2011) Annual Meeting of the American Society for Surgery of the Hand, 69 presentations were evaluated by at least 2 independent observers. A rating instrument was developed a priori to examine presentation content (background, methods, results, and conclusions), presentation style (speech, structure, delivery, slide aesthetics), and overall quality. We examined correlations between reviewers' ratings of each component as well as overall perceived quality of the presentation using regression analysis. Intraclass correlation coefficients were calculated to measure the degree of variation because of reviewer disagreement and identify the aspects of presentations that contribute to overall quality. RESULTS: Reviewer agreement was high for presentation content, and less than 1% of variation was caused by reviewer disagreement for background, methods, and conclusions. With respect to presentation style, reviewers agreed most frequently regarding speech and slide appearance, and only 9% and 13%, respectively, of the variation was caused by reviewer disagreement. Disagreement was higher for delivery and presentation structure, and 21% of the variation was attributable to reviewer disagreement. Speaker delivery and slide appearance were the most important predictors of presentation quality, followed by the quality of the presentation of conclusions and background information. Presentation of methods and results were not associated with overall presentation quality. CONCLUSIONS: Distinct aspects of presentation content and style correlate with quality, which can be reliably and objectively measured. By focusing on selected concepts with visually simple slides, speakers can enhance their delivery and may potentially improve the audience's comprehension of the study findings.

Schwannoma of the hand in an infant: case report.

Schwannomas (neurilemmomas) are the most common benign tumors of peripheral nerves and originate from the myelinating cells of the nerve sheath. We present a case of congenital schwannoma of the hand.

A case of breast reconstruction with bilaterally divided transverse rectus abdominis musculocutaneous flaps after removal of injected silicone and granuloma.

We present a case of breast reconstruction using bilaterally divided transverse rectus abdominis musculocutaneous flaps after the removal of severe siliconoma. In Japan, we have examined many patients who have had foreign substance injected into the breasts for augmentation. Most of these patients have had delayed complications. We believe that autologous tissue transfer is an ideal procedure for breast reaugmentation in patients who want to have artificial materials removed from the breasts but to maintain breast contour.

Reconstruction of elbow region defects using radial collateral artery perforator (RCAP)-based propeller flaps.

Perforator-based propeller flaps permit flap rotation up to 180°. This ability to transfer skin from one longitudinal axis to another has led to the increasing use of perforator-based propeller flaps in extremity reconstruction, especially lower-extremity reconstruction. However, the application of perforator-based propeller flaps to upper-extremity reconstruction is still limited. This article reports two cases of successful reconstruction of elbow region defects with radial collateral artery perforator (RCAP)-based propeller flaps. The elbow region has a variety of perforators available for perforator-based propeller flap reconstruction. Among them, the RCAP seems to be one of the most reliable options. This is because there are less anatomical variations of perforators' location on the lateral upper arm than on the medial upper arm. By using an RCAP perforator as a flap pedicle, the small-to-medium sized defects (<6 cm in diameter) around elbow regions can be closed primarily without skin grafts.