An alternative mucosal flap for nasal lining: the superior labial artery mucosal flap-an anatomic study.

Reconstruction of nasal lining and septal defects is a challenging problem. An ideal reconstructive option provides ample thin, like tissue with reliable perfusion in a relatively short, single-staged procedure. The purpose of this study is to describe the vascular anatomy of the superior labial artery and an axial mucosal flap, the superior labial artery mucosal flap, based on this vascular pedicle, proposed for a single-stage reconstruction of nasal lining and septal defects.Dissection of the 10 facial arteries and their branches with a focus on the superior labial arteries was performed in a total of 5 fresh human cadavers. Objective findings on the vascular anatomy were assessed and upper lip mucosal flaps, medially based on the superior labial artery, were elevated. The case of a 30-year-old man who sustained a dog bite to the nose with a resulting full-thickness loss of his entire nasal tip and partial loss of his alar subunits is presented.In complex cases of nasal reconstruction in which nasal lining of associated defects cannot be accomplished with local flaps, we describe the anatomic basis for a regional single-staged, axial flap alternative for reconstruction.

Utilizing international consensus panel recommendations and a clinical decision tree to guide selection of negative pressure wound therapy.

INTRODUCTION: A variety of NPWT products have become commercially available in the last 30 years. Utilizing advanced wound therapies appropriately can improve patient outcomes and decrease health care expenditures. Due to the increasing number of available product options, Hurd and colleagues published 10 Consensus Statements and a clinical decision tree to provide guidance on how and when to use NPWT and when to transition between device types. OBJECTIVE: To demonstrate the applicability of the consensus panel's statements and the clinical decision tree, 2 clinicians in the United States and Canada explored the benefits of applying these recommendations into their routine wound management practice. MATERIALS AND METHODS: Case studies were collected and reviewed in accordance with the Consensus Statements and clinical decision tree. RESULTS: Case presentations illustrate the application of the consensus panel's guidance through the prescribing of the NPWT products utilized as standard of care within both facilities. CONCLUSION: Utilizing NPWT devices according to the consensus panel recommendations and the clinical decision tree may assist in optimizing care delivery to patients and address logistical and economic efficiencies.

A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly.

PURPOSE: As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI). METHODS: We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study. RESULTS: We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention. CONCLUSIONS: This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods.

International Consensus Panel Recommendations for the Optimization of Traditional and Single-Use Negative Pressure Wound Therapy in the Treatment of Acute and Chronic Wounds.

INTRODUCTION: Currently, there are no international standardized guidelines or recommendations to guide the clinical decision-making process on when to initiate various negative pressure wound therapy (NPWT) systems for acute and chronic wounds. Specifically, no established recommendations or guidance exists regarding the type of NPWT system to use, traditional (tNPWT) or single-use (sNPWT), and how to transition between the 2 systems. METHODS: An expert panel was convened to (1) provide recommendations to clinicians on when to consider NPWT use in acute and chronic wound management and (2) develop a practical decision-making tool to guide on the appropriateness of the different NPWT modalities (tNPWT or sNPWT) and when they should be utilized. RESULTS: The panel made recommendations and designed a clinical decision-making tool to aid the consideration for initiating NPWT and the optimal system to be utilized based on (1) therapeutic goals, (2) wound-related factors, (3) patient satisfaction and quality of life, (4) care setting-related factors, (5) economic-related factors, and (6) NPWT system-related factors. CONCLUSIONS: The panel recommendations took into consideration the clinical, operational, and financial factors in the clinical decision-making process of NPWT use to enable optimal patient and health care system outcomes.

Factors Influencing American Plastic Surgery Residents Toward an Academic Career.

BACKGROUND: Plastic surgery residency program directors have an interest in recruiting applicants who show an interest in an academic practice. Medical school achievements (ie, United States Medical Licensing Examination® scores, publications, and Alpha Omega Alpha status) are metrics assessed to grade applicants but may not correlate with ultimately choosing an academic career. OBJECTIVE: This study was designed to investigate factors influencing residents' choices for or against academic careers. METHODS: A 25-item online questionnaire was designed to measure baseline interest in academic plastic surgery and factors that influence decisions to continue on or abandon that career path. This questionnaire was disseminated to the integrated/combined plastic surgery residents during the 2013 to 2014 academic year. RESULTS: One hundred twenty-five respondents indicated that they were currently interested in pursuing academic practice (n = 78) or had lost interest in academic practice (n = 47). Among all respondents, 92.8% (n = 116) stated they were interested in academic careers at the time of residency application, but one-third (n = 41) subsequently lost interest. Those residents who retained interest in academic careers indicated resident/medical student educational opportunities (57%) and complexity of patients (52%) as reasons. Those who lost interest cited a lack of autonomy (43%), publishing requirements (32%), and income discrepancy (26%) as reasons. DISCUSSION: Many residents report losing interest in academics during residency. Traditional metrics valued in the recruitment process may not serve as positive predictors of an academic career path. CONCLUSION: Reasons why residents lose interest are not easily correctable, but mentorship, adequate career counseling, and research opportunities during training remain factors that can be addressed across all residency programs.

HISTORIQUE: Les directeurs des programmes de résidence en chirurgie plastique ont intérêt à recruter des candidats qui souhaitent mener une carrière en milieu universitaire. Les réalisations en faculté de médecine (indices de l'USMLE, publications et statut à l'AOA) sont des mesures utilisées pour classer les candidats, mais elles ne sont peut-être pas corrélées avec le choix d'une carrière en milieu universitaire. OBJECTIF: La présente étude visait à évaluer les facteurs qui influent sur les choix des résidents à opter ou non pour une carrière en milieu universitaire. MÉTHODOLOGIE: Les chercheurs ont conçu un questionnaire en ligne de 25 questions pour mesurer l'intérêt de départ envers une carrière en chirurgie plastique en milieu universitaire et les facteurs qui influent sur la décision de poursuivre en ce sens ou non. Ils l'ont distribué aux résidents en chirurgie plastique intégrés ou combinés pendant l'année scolaire 2013-2014. RÉSULTATS: Au total, 125 répondants ont affirmé s'intéresser à une carrière en milieu universitaire (n = 78) ou avoir perdu leur intérêt envers la pratique universitaire (n = 47). Dans l'ensemble, 92.8 % d'entre eux (n = 116) ont affirmé qu'ils envisageaient de mener une carrière en milieu universitaire au moment de leur demande de résidence, mais le tiers (n = 41) a ensuite perdu cet intérêt. Parmi leurs raisons, les résidents qui continuaient de vouloir mener une carrière en milieu universitaire ont cité les possibilités d'enseignement aux résidents et aux étudiants en médecine (57 %) et la complexité des cas (52 %). Ceux qui avaient perdu l'intérêt ont invoqué le manque d'autonomie (43 %), les exigences en matière de publication (32 %) et l'écart du revenu (26 %). EXPOSÉ: De nombreux résidents ont déclaré perdre leur intérêt envers une carrière en milieu universitaire pendant leur résidence. Les mesures habituelles utilisées pendant le processus de recrutement ne sont peut-être pas des prédicteurs positifs d'un cheminement de carrière universitaire. CONCLUSION: Les raisons pour lesquelles les résidents perdent l'intérêt envers la carrière en milieu universitaire ne sont pas faciles à corriger, mais le mentorat, une bonne orientation de carrière et des occasions de recherche pendant la formation font partie des facteurs qui peuvent être abordés dans tous les programmes de résidence.

A Comprehensive Guide on Restoring Grasp Using Tendon Transfer Procedures for Ulnar Nerve Palsy.

Ulnar nerve paralysis results in classic stigmata, including weakness of grasp and pinch, poorly coordinated flexion, and clawing of digits. Restoration of grasp is a key portion of the reconstructive efforts after loss of ulnar nerve function. Improving flexion at the metacarpophalangeal joint can be done by static and dynamic means, although only the latter can improve interphalangeal extension. Deformity and digital posture are more predictably corrected with surgical intervention. Loss of strength from intrinsic muscle paralysis cannot be fully restored with tendon transfer procedures. Preoperative patient education is paramount to success if realistic expectations are to be met.

Mortality trends and the effects of débridement timing in the management of mediastinitis in the United States, 1998 to 2010.

BACKGROUND: The authors examined the relationship between débridement delay and mortality for mediastinitis patients. The authors also assessed mortality trends for mediastinitis patients between 1998 and 2010. METHODS: The authors conducted a retrospective cross-sectional study with data from the Nationwide Inpatient Sample, 1998 to 2010. They studied adult patients, 18 years of age or older, who were surgically treated for mediastinitis. They used a logistic regression model adjusted for patient demographic and clinical characteristics to evaluate the association between timing of first operative débridement and in-hospital mortality. Using their logistic model, they calculated the adjusted probability of in-hospital mortality for each year of the study. RESULTS: Results showed that initial débridement after the fourth day of admission increased the odds of in-hospital mortality by 50 percent (odds ratio, 1.5; 95 percent confidence interval, 1.0 to 2.1). In addition, the adjusted probability of in-hospital mortality for an average patient treated for mediastinitis decreased from 10.6 percent in 1998 to 3.1 percent in 2010. CONCLUSION: There is a survival advantage from timely initial débridement in mediastinitis patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The evolution of distal radius fracture management: a historical treatise.

Distal radius fractures (DRFs) have been a common affliction for millennia, but their treatment is a more recent development resulting from human erudition. Although immobilization has served as the only available treatment for most of our history, many advances have been made in the management of DRFs over the last century as orthopedics has grown. Yet the topic remains hotly contested in the literature and, given the frequency of the injury, research continues to focus on it. This article traces the evolution of DRF treatment to provide a context for the future.

Common myths and evidence in the management of distal radius fractures.

Distal radius fractures (DRFs) are the most common fracture treated by physicians, but questions remain regarding optimal management. Fracture patterns, biomechanics, and treatment strategies have been debated for more than 200 years, and research shows many controversies regarding long-held beliefs. Although these common myths have been propagated and considered fact, they are not based on the best-available evidence. This article illustrates some of the major controversies regarding the management of DRFs. To provide optimal care in a world of evidence-based medicine, clinicians must shift their thinking and accept that some of the indoctrinated ideas may represent a flawed heuristic approach.