Surgical Management in Isolated Squamosal Craniosynostosis: A Systematic Review.

BACKGROUND: Although craniosynostoses involving the major sutures have been well described, the frequency of isolated minor suture craniosynostoses is much lower. Squamosal craniosynostosis (SQS) is a rare form of cranial synostosis, and the paucity of literature has made the creation of a standardized treatment plan difficult. We present a systematic review of the literature on isolated SQS to identify disease characteristics that lead to a need for operative intervention and to delineate patterns in surgical management. METHODS: A systematic literature review was performed using the electronic databases of PubMed, Scopus, and MEDLINE and the key words "squamosal AND craniosynostosis," "squamous AND craniosynostosis," "squamosal craniosynostosis, "squamosal suture craniosynostosis," and "isolated squamosal craniosynostosis." Only human studies that described presentation and management of SQS were included. A blinded, 2-reviewer analysis of the articles was performed. Data collected included patient and disease characteristics, imaging workup, and treatment specifics, which were analyzed by descriptive statistics. RESULTS: A total of 19 studies examining 119 patients with SQS were reviewed, with 97 (82%) multisutural cases and 22 isolated cases (18%). Of the isolated cases, 6 (27%) required surgical craniosynostosis repair, of which 1 (17%) had unilateral sutural involvement and 5 (83%) had bilateral involvement. Of the patients with isolated SQS, 7 (32%) had a congenital syndrome and comprised 33% of patients who required surgical intervention. The nonsyndromic patients with isolated SQS who required surgery presented with a wide array of phenotypic findings; 3 patients underwent some form of cranial vault remodeling, whereas 1 patient underwent ventriculoperitoneal shunt only. Of the 4 nonsyndromic patients with isolated SQS who underwent surgical repair, half required operative intervention because of elevated intracranial pressure and the other half because of dysmorphic head shape. CONCLUSION: The findings of this updated systematic review suggest a trend toward surgical management in bilateral SQS versus unilateral SQS, and that patients with isolated SQS, previously considered to be a nonsurgical finding, should be carefully monitored, as there remains risk of increased intracranial pressure. Pooled systematic review data suggest isolated SQS has a 27% operative intervention rate, with the presence of coexisting syndromic diagnoses increasing that risk.

Skin Popping for the Hand Surgeon: A Case Report and Review.

INTRODUCTION: Subcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery. METHODS: A case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria. RESULTS: In this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described. CONCLUSIONS: Skin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of "skin popping" sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.

Microaggressions and Implicit Bias in Hand Surgery.

Implicit bias and microaggressions are well-known phenomenon and have recently been acknowledged as contributing to health care disparities. Within Hand Surgery, implicit bias and microaggressions occur in patient-surgeon, surgeon-peer, surgeon-staff, and training environment interactions. Although racial and gender biases are well studied, biases can also be based on age, sexual orientation, socioeconomic background, and/or hierarchal rank. Academia has well-documented evidence of implicit bias and microaggressions, contributing to current disparate demographics of trainees, physicians, and leaders within Hand Surgery. Awareness is fundamental to combating bias and microaggressions; however, actions must be taken to minimize negative effects and change culture.

Compression Screw Fixation of Lunate Fracture: Case Report and Review of the Literature.

Background Isolated traumatic lunate fractures without other surgical carpal bone or ligamentous injuries are extremely rare, with few published reports available to guide management. Lunate fracture management is controversial, and depends on concurrent injuries of adjacent carpal bones, ligaments, risk of ischemia, and displacement. Case Description A 48-year-old right hand dominant man suffered a crush injury to the left hand caught between a forklift and a metal shelf. Radiographs and computed tomography imaging of the left hand and wrist were significant for a displaced Teisen IV fracture of the lunate. A dorsal ligament sparing approach was utilized to access, reduce, and fixate the fracture using a headless compression screw. After immobilization and rehab, at 9 months after initial injury, the patient was back to work on full duty without restriction and pleased with the results of his treatment. Literature Review A literature review of lunate fracture compression screw fixation was performed and revealed a total of three reports indicating successful treatment of fractures, with patients returning to full activity. Clinical Relevance Lunate fractures are rare, often missed, and treating these injuries can be challenging, particularly in the setting of acute trauma. Based on our limited experience, we believe that open reduction and internal fixation of isolated Teisen IV lunate fractures with a headless compression screw is a viable treatment modality with satisfactory outcomes.

The Use of Arteriovenous Bundle Interposition Grafts in Microsurgical Reconstruction: A Systematic Review of the Literature.

Microvascular reconstruction frequently requires anastomosis outside of the zone of injury for successful reconstruction. Multiple options exist for pedicle lengthening including vein grafts, arteriovenous loops, and arteriovenous bundle interposition grafts. The authors performed a systematic review of arteriovenous bundle interposition grafts to elucidate indications and outcomes of arteriovenous grafts in microvascular reconstruction. A systematic review of the literature was performed using targeted keywords. Data extraction was performed by two independent authors, and descriptive statistics were used to analyze pooled data. Forty-four patients underwent pedicle lengthening with an arteriovenous graft from the descending branch of the lateral circumflex femoral artery. Most common indications for flap reconstruction were malignancy ( n = 12), trauma ( n = 7), and diabetic ulceration ( n = 4). The most commonly used free flap was the anterolateral thigh flap ( n = 18). There were five complications, with one resulting in flap loss. Arteriovenous bundle interposition grafts are a viable option for pedicle lengthening when free flap distant anastomosis is required. The descending branch of the lateral circumflex femoral artery may be used for a variety of defects and can be used in conjunction with fasciocutaneous, osteocutaneous, muscle, and chimeric free flaps.

Serratus Anterior-rib Composite Flap Partial Thumb Reconstruction.

The serratus anterior-rib composite flap is a well described and versatile flap used for reconstruction in a variety of anatomical regions. However, reconstruction of a thumb defect using this flap has not been well described since first mentioned in the literature by the Buncke et al group 20 years ago. The authors describe the use of this technique for thumb reconstruction in a complex defect from a gunshot wound.

Common Hand Conditions: A Review.

Importance: Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability. Observations: Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments. Conclusions and Relevance: Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.

Efficacy of Microsurgical Treatment of Primary Lymphedema: A Systematic Review.

INTRODUCTION: Treatment of lymphedema remains a challenging clinical problem. Lymphatic surgery has recently gained momentum as an effective method to treat both early- and late-stage disease. In particular, "physiologic" microsurgical techniques including vascularized lymph node transplant and lymphovenous bypass/anastomosis have been shown to be effective in treating even advanced lymphedema. Most published reports describe techniques and success in secondary lymphedema. Traditionally, physiologic surgery was not believed to be useful in the treatment of primary lymphedema where baseline lymphatic function is abnormal. However, recent studies have shown a benefit in these cases. The objective of this study is to evaluate outcomes and complications of physiologic microsurgical treatment for primary lymphedema. METHODS: The electronic databases of PubMed, Scopus, and MEDLINE were searched using key words "primary lymphedema" and "surgery" (also vascularized lymph node transplant, lymphovenous bypass, microsurgery). Only human studies published between 2000 and 2021 were included. Studies that only included ablative or resection surgeries were excluded. RESULTS: A total of 10 studies comprising 254 patients with primary lymphedema who underwent 357 physiologic microsurgical operations were included. Lymphovenous bypass comprised 88% of cases, and in the patients who underwent vascularized lymph node transplant, all but 1 flap survived. Regardless of type of operative intervention, all studies showed a statistically significant improvement in lymphedema, through either reduction in limb circumference or edema volume or improvement in quality of life. DISCUSSION: Physiologic lymphatic surgery has shown success and improvement for patients with primary lymphedema. Based on current literature, physiologic surgical treatment of primary lymphedema should be considered when treating this patient population.

Pediatric Trigger Digit Presenting in the Setting of Trauma.

BACKGROUND: Pediatric trigger digit is a relatively rare condition with incompletely understood etiology. In our practice, we noted a series of children presenting with pediatric trigger digit after an associated local trauma to the hand, which has not been previously described. The aim of this study was to analyze the nature of presentation of trigger digits, the accuracy of initial diagnosis, and the impact on treatment strategies used. METHODS: An institutional review board-approved retrospective review of our institution's experience with pediatric trigger finger from 2001 to 2015 was performed. RESULTS: Twenty-two patients with 26 affected digits were identified. Eighty-eight percent of patients were diagnosed with trigger thumb, whereas 3 patients (12%) had small finger triggering. Thirteen patients (59%) presented as outpatients, whereas 9 (41%) presented through the emergency department. All patients presenting to the emergency department were in the setting of recent minor trauma. Of this subset of patients, 67% had an incorrect initial diagnosis, leading to an average delay in treatment of 60 days. Ten patients (45% of total) were initially treated with immobilization versus surgical release of the A1 pulley. However, all but 2 of these patients required eventual A1 pulley release for persistent or recurrent triggering (88%). CONCLUSIONS: The cause of trigger digit in children remains incompletely understood and may be multifactorial. In this series, a traumatic component to presentation was found in a significant number of patients. This association with minor trauma may contribute to misdiagnosis and delay in definitive treatment. Although initial treatment with immobilization does not seem to impact surgical outcome, we found a high rate of failure with initial immobilization. Most patients required eventual surgical management, regardless of whether or not the initial presentation was associated with trauma. When performed, we found that A1 pulley release alone has safe, reliable results.

Lymphovenous Bypass Using Indocyanine Green Mapping for Successful Treatment of Penile and Scrotal Lymphedema.

Male genital lymphedema is a debilitating condition with significant physiologic and psychologic ramifications. Classical surgical treatments for male genital lymphedema include primarily ablative procedures through removal of excess soft tissue, which often have poor aesthetic and functional outcomes. Super microsurgical techniques (including lymphovenous bypass and lymph node transfers) are promising contemporary interventions. In this case report, we aim to share our experience of lymphovenous bypass with indocyanine green (ICG) lymphangiography in the management of penile and scrotal lymphedema. We performed ICG lymphography of the male genitalia and right thigh by injecting ICG at multiple sites followed by concomitant evaluation with a handheld fluorescent portable imager. Skin incisions were designed over the linear lymphatics upstream from the site of obstruction and dermal backflow. Four end-to-end and one end-to-side lymphovenous bypasses were performed. After completion, lymphovenous bypasses patency was confirmed by injecting ICG proximal to the incision and observing flow. At 10-month clinic follow-up, the patient showed marked improvement with improved skin tenting, softer tissues, improved sensation, visible dorsal penile vein, ability to retract foreskin for cleaning, and confidence to engage in sexual activities. This case report describes successful use of lymphovenous bypass in the treatment of penile and scrotal lymphedema using ICG lymphography intraoperatively to map functioning of superficial lymphatics. The full potential of this microsurgical approach is yet to be discovered, and future studies are needed to enhance the long-term outcomes for the treatment of penoscrotal lymphedema.

Temporomandibular Joint Septic Arthritis.

Infection of the temporomandibular joint (TMJ) is a rare pediatric condition resulting from the introduction of pathogens into the joint by hematogenous seeding, local extension, or trauma. Early recognition of the typical signs and symptoms including fever, trismus, preauricular swelling, and TMJ region tenderness are critical in order to initiate further evaluation and prevent feared complications of fibrosis, ankylosis, abnormal facial structure, or persistence of symptoms. Contrast-enhanced computed tomography with ancillary laboratory analysis including erythrocyte sedimentation rate, C-reactive protein, and white blood cell count are beneficial in confirming the suspected diagnosis and monitoring response to therapy. Initial intervention should include empiric parenteral antibiotics, early mandibular mobilization, and joint decompression to provide synovial fluid for analysis including cultures. This report describes a case of TMJ bacterial arthritis in a healthy 6-year-old male who was promptly treated nonsurgically with intravenous antibiotics and localized needle joint decompression with return to normal function after completion of oral antibiotics and physical therapy.

Squamosal Craniosynostosis: Defining the Phenotype and Indications for Surgical Management.

BACKGROUND: Squamosal craniosynostosis is seldom reported in the craniofacial literature. Given that this is an uncommon diagnosis, phenotype and management remain unclear. The authors present a case series and review the literature to define the phenotype and management of these patients. METHODS: We retrospectively reviewed 7 patients from our institution and systematically reviewed all published cases of squamosal craniosynostosis. Demographics, medical history, imaging, clinical presentation, subsequent workup, and treatment were examined and analyzed. RESULTS: A comprehensive review of the literature yielded a total of 31 cases (including our new series) of squamosal craniosynostosis. Average age of presentation was 25.3 months, 52% of female patients, 74% of cases with bilateral squamosal involvement, 44% syndromic, 39% isolated squamosal (vs 61% multisutural). Overall, 56% of cases were handled surgically, whereas 44% were managed conservatively. Thirty-three percent of surgical cases required multiple operations. One patient with isolated bilateral squamosal craniosynostosis developed elevated intracranial pressure, requiring cranial vault remodeling. CONCLUSIONS: Squamosal craniosynostosis frequently presents in a delayed fashion with nonsyndromic, bilateral involvement. In isolated bilateral squamosal cases, the associated phenotype is frontal prominence, occipital flattening, scaphocephalic tendency (low-end normocephalic cranial index), and superior parietal cornering. Evaluation of clinical signs and computed tomography imaging guides management, as evidence of increased intracranial pressure may indicate need for cranial vault expansion. Although previous literature suggests that nonsyndromic cases are nonsurgical, the majority of cases reviewed required surgical intervention, including our case of isolated bilateral squamosal craniosynostosis. We recommend vigilant management in patients with squamosal craniosynostosis, even those with isolated squamosal involvement.

The Simultaneous Use of Breast Reduction and Internal Mammary Artery Perforator Flap in Sternal Wound Reconstruction.

Internal mammary artery perforator (IMAP)-based fasciocutaneous flaps have recently gained popularity in sternal wound reconstruction due to their decreased donor site morbidity. However, patients with significant macromastia or who are obese present a challenge when using these flaps due to their anatomy and associated comorbid conditions. Despite the prevalence of this population, there is a relative paucity of data on the use of local fasciocutaneous flaps and techniques to close sternotomy wounds in the obese population with hypertrophic or ptotic breasts. The authors describe a novel technique using simultaneous unilateral breast reduction with a fifth intercostal IMAP-based flap for closure of a median sternotomy wound through a case presentation, an anatomical injection study, and review of the literature. Five fresh female cadavers were used to conduct 8 trials of injection of the IMAP arteries, isolation of the fifth IMAP branch, and elevation of a local flap. The literature was comprehensively reviewed with a total of 33 cases of IMAP flaps for sternal reconstruction being described. The most commonly used perforators with the second and sixth IMAPs. Overall complication rate was reported to be 9.1% (3/33), with 2 cases reporting dehiscence and 1 with flap tip necrosis. No cases reported use of the fifth IMAP or formal breast reduction procedures, which was successfully performed in a 40-year-old diabetic female patient history of multiple left-sided thoracic surgeries and radiation with a chronic sternal wound.

The Plastic Surgery Match: A Quantitative Analysis of Applicant Impressions From the Interview Visit.

BACKGROUND: The integrated plastic surgery match is a competitive process not only for applicants but also for programs vying for highly qualified candidates. Interactions between applicants and program constituents are limited to a single interview visit. The authors aimed to identify components of the interview visit that influence applicant decision making when determining a final program rank list. METHODS: Thirty-six applicants who were interviewed (100% response) completed the survey. Applicants rated the importance of 20 elements of the interview visit regarding future ranking of the program on a 1 to 5 Likert scale. Data were analyzed using descriptive statistics, hierarchical cluster analysis, analysis of variance, and Pearson correlations. A literature review was performed regarding the plastic surgery integrated residency interview process. RESULTS: Survey questions were categorized into four groups based on mean survey responses:1. Interactions with faculty and residents (mean response > 4),2. Information about the program (3.5-4),3. Ancillaries (food, amenities, stipends) (3-3.5),4. Hospital tour, hotel (<3).Hierarchical item cluster analysis and analysis of variance testing validated these groupings. Average summary scores were calculated for the items representing Interactions, Information, and Ancillaries. Correlation analysis between clusters yielded no significant correlations. A review of the literature yielded a paucity of data on analysis of the interview visit. CONCLUSIONS: The interview visit consists of a discrete hierarchy of perceived importance by applicants. The strongest independent factor in determining future program ranking is the quality of interactions between applicants and program constituents on the interview visit. This calls for further investigation and optimization of the interview visit experience.

Who is Publishing in Facial Cosmetic Surgery? A Citation Analysis Across Specialties Over Five Decades.

BACKGROUND: Competition among our sister cosmetic specialties continues to increase. Once a field dominated by plastic surgeons, there is a clear trend toward increased competition from core and non-core disciplines. While these marketplace trends are obvious, how such competition has affected academia or peer reviewed publications is less clear. OBJECTIVES: We analyzed the most cited peer reviewed facial aesthetic literature over the past five decades to see if marketplace trends are echoed in a similar manner across the academic disciplines of plastic surgery, otolaryngology, dermatology, and ophthalmology. METHODS: The top 50 cited articles for each decade from the 1970s to the 2010s were identified for the topics of facelift, rhinoplasty, browlift, and blepharoplasty using the Thomson/Reuters Web of Knowledge. Data collected were: the number of citations/article, first authors' specialty affiliation, and journal specialty affiliation. Data were plotted graphically and trends were analyzed. RESULTS: With regards to first authorship, plastic surgery had the highest percentage across all surgeries at every time point, except for rhinoplasty from 2010-present, when otolaryngology had a higher percentage (48% vs 40%). Observed trends demonstrated: (1) increasing contributions from otolaryngology in rhinoplasty, facelift, and browlift; and (2) increasing contributions from ophthalmology in blepharoplasty. Plastic surgery journals are the most common platform for publication across all four surgeries. CONCLUSIONS: Plastic surgeons, and plastic surgery journals, still remain a strong force in academic facial cosmetic surgery. However, it appears that the competition from non-plastic surgeons observed in clinical practice is being mirrored in the area of journal publications. We as a specialty need to continue to strive for high quality academic productivity.

Applying to Integrated Plastic Surgery Residency Programs: Trends in the Past 5 Years of the Match.

BACKGROUND: The average integrated plastic surgery applicant spends over $6000 for interviews. The average program director reviews over 200 applications per cycle. It is important to make the application process efficient and cost effective for both applicants and programs. The authors analyzed recent trends and the literature in an attempt to increase the likelihood that applicants match, suggest means of reducing applicants' costs, and improve the process. METHODS: A cross-sectional study of the National Residency Matching Program Charting Outcomes and results and data for the years 2009 to 2014 was performed. Applicant profile elements were examined for differences between matched/unmatched U.S. senior medical students. In addition, a literature review was performed. RESULTS: The number of integrated plastic surgery positions rose from 69 in 2010 to 130 in 2014. Both matched and unmatched U.S. senior medical students have higher Step 2 scores, research and volunteer experiences, than 5 years ago. The likelihood of matching into an integrated plastic surgery residency has increased (2009, 52 percent; 2011, 44 percent; and 2014, 71 percent). Successful match rates were associated with Alpha Omega Alpha status and graduating from a top-40 ranked medical school (p < 0.05). Applicants with a lower number of ranked programs had increased match rates in 2014 than in previous years. Literature review revealed that program directors also value strong recommendation letters, publications, persistent work ethic ("grit"), away rotations, and an accurate curriculum vitae. CONCLUSIONS: Within the setting of increased applicant competitiveness, the authors recommend maximizing subjective qualities in order to differentiate themselves from a highly eligible applicant pool. In addition, applicants should diversify the types of programs at which they interview to maximize their chances of matching.

A comprehensive examination of topographic thickness of skin in the human face.

BACKGROUND: Knowledge of topographic skin thickness is important to plastic surgery of the face as it may guide resection and restoration in oncologic, aesthetic, and reconstructive procedures. OBJECTIVE: The purpose of this study is to report the relative thickness of the face throughout 39 distinct subunits. METHODS: Full-thickness punch biopsy samples were obtained at 39 predetermined anatomic locations of the face from 10 human cadaveric heads. Tissue was fixed in paraffin-embedded slides and analyzed using triplicate measurement of dermis and epidermis using computerized measurements. Data were analyzed using univariate statistical analysis and expressed as mean thickness values and relative thickness (RT) values based on the thinnest portion of the face. RESULTS: The area of the face with the thickest dermis was the lower nasal sidewall (1969.2 µm, dRT: 2.59), and the thinnest was the upper medial eyelid (758.9 µm, dRT: 1.00). The area with the thickest epidermis was the upper lip (62.6 µm, eRT: 2.12), and the thinnest was the posterior auricular skin (29.6 µm, eRT: 1.00). Our results confirm that eyelid skin is the thinnest in the face. The thickest portions of the skin appeared to be in the lower nasal sidewall, but the measurements are comparable to those in the ala and posterior auricular skin, which are novel findings. CONCLUSIONS: The greatest epidermal, dermal and total skin thickness are found in the upper lip, right lower nasal sidewall, and left lower nasal sidewall respectively. The least epidermal skin thickness is in the posterior auricular skin. The least dermal skin thickness, and the least total skin thickness, are both in the upper medial eyelid.