Zone I Flexor Digitorum Profundus Repair: A Surgical Technique.

We present an all-inside technique for zone I flexor tendon repair that combines suture anchor fixation with buried back-up fixation. The back-up fixation uses transosseous tunnels and a dorsal counterincision to allow a suture tied dorsal to the distal phalanx and buried. This technique is strong and permits early active range of motion. The dorsal tie-over does not require a suture button and, therefore, does not imperil the nail matrix. The surgical technique is herein described including the proposed anesthesia (wide awake), the incisions (midlateral), the exposures, and the repair itself.

Anatomical Variation of the Radial Artery Associated With Clinically Significant Ischemia.

PURPOSE: The purpose of this retrospective review was to investigate the incidence of radial artery anatomical variations in patients with clinically significant distal upper extremity (UE) ischemia. Available anatomical studies report that high takeoff of the radial artery occurs in up to 15% of the population. We hypothesized that there is a higher incidence of high origin of the radial artery in patients with clinically significant ischemia compared with the reported frequency in the general population. METHODS: We performed a retrospective review of all patients who underwent UE angiography for clinically significant hand and digital ischemia in our institution from 2012 to 2016. Data collected included patient age, sex, comorbidities, and modality of treatment. RESULTS: Twenty-six angiograms were performed for UE ischemia meeting inclusion criteria. Eight patients had Raynaud disease or scleroderma. Ten patients (38%) had high radial artery takeoff with radial artery origin proximal to the antecubital fossa. The need for surgical intervention was similar in patients with normal anatomy and those with high takeoff of the radial artery. CONCLUSIONS: Incidence of high radial artery takeoff was found more frequently in patients with distal UE ischemia requiring angiogram than in reported population data. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Acellular dermal matrix reduces capsule formation in two-stage breast reconstruction.

Acellular dermal matrix (ADM) is commonly employed to create an inferior pocket for the tissue expander in two-stage breast reconstruction. The authors sought to determine whether placement of ADM during the first stage of reconstruction decreases the amount of capsule formation at implant exchange. Patients who underwent mastectomy and tissue expander reconstruction were included in this study. Two biopsies were obtained at the time of implant exchange, one from the pocket adjacent to the ADM and the other from the area adjacent to the pectoralis muscle. Pathology analysis was performed on each sample. Ten patients underwent immediate breast reconstruction with Alloderm during the 3-month study period. Capsule thickness was significantly greater in the areas where the expander was in direct contact with the pectoralis muscle (782 ± 194 µm) compared to those in contact with human acellular dermal matrix (hADM) (47·91 ± 110·82 µm; P < 0·05). Analysis of the sub-pectoral capsule demonstrated diffuse deposition of collagen, neutrophils, contractile myofibroblasts and synovia-like metaplasia, characteristic of a foreign body response. Conversely, within the inferior pocket where the hADM was in direct contact with the expander, we noted migration of host epithelial cells, fibroblasts, mesenchymal cells and angiogenesis, indicating host tissue regeneration. Acellular dermal matrix, when placed at the first stage of breast reconstruction, significantly reduces thickness and inflammatory character of the capsule in comparison to the patient's native tissue.

Porcine Acellular Dermal Matrix for Hernia Repair in Transplant Patients.

PURPOSE: The purpose of this study was to compare clinical outcomes of incisional hernia repair in solid organ transplant patients using non-cross-linked porcine acellular dermal matrix (PADM), human derived acellular dermal matrix (HADM) and synthetic mesh. METHODS: A retrospective review of patients who underwent hernia repair with PADM after pancreas and/or renal transplant at the University of Maryland Medical Center from 2008 to 2012 was conducted. Repair type, postoperative infection, hernia recurrence, mesh removal, and length of follow-up were recorded. Results were compared with our previously published data evaluating HADM and synthetic mesh used in transplant patients between 2000 and 2005. RESULTS: Twenty-seven patients underwent ventral hernia repair with PADM, 34 patients were repaired with HADM and 26 were repaired with synthetic mesh. The rate of wound infection in those repaired with PADM, HADM, and synthetic mesh were 14.8%, 14.7%, and 65.4%, respectively. Rates of recurrence were 13.3%, 23.5%, and 76.9%, respectively. Rate of mesh removal was found to be 7.4%, 11.8%, and 69.2%, respectively. These complication rates were significantly lower in patients who received HADM or PADM compared with patients repaired with synthetic mesh (P < 0.001). There was no statistically significant difference in the outcomes between the groups repaired with HADM or PADM. CONCLUSIONS: The use of PADM for incisional hernia repair after kidney and/or pancreas transplant significantly reduces the incidence of hernia recurrence, wound infection, and need for mesh removal compared to synthetic mesh. No difference in morbidity between HADM and PADM was observed in the study population; however, longer follow-up in the PADM group is warranted.

Porcine acellular dermal matrix (PADM) vascularises after exposure in open necrotic wounds seen after complex hernia repair.

Biological alternatives to synthetic meshes are increasingly utilised in complex abdominal wall reconstruction. There is a lack of evidence demonstrating that non-cross-linked porcine acellular dermal matrix vascularizes and integrates with human tissue in suboptimal wound conditions. We aimed to evaluate these properties in Strattice™ (Life Cell Inc., Branchburg, NJ) following ventral hernia repair. A retrospective review of patients with high-risk ventral hernia repair utilising Strattice™ as an onlay after open component separation was conducted. Patients with postoperative wound exploration and exposure of the onlay were included in this review. One patient underwent punch biopsy for histological analysis. Eleven patients with wound complications necessitating postoperative debridement and exposure of Strattice™ onlay were identified. The onlay was partially debrided in two cases, and one case required complete excision. Vascularisation was clinically evident in 10 of 11 cases (91%) as demonstrated by the presence of granulation tissue and/or the ability to support a skin graft. Histological analysis of one onlay 3 months postoperatively showed neovascularisation and collagen remodelling with minimal inflammatory response. Strattice™ demonstrated resistance to rejection, ability to undergo vascularisation and incorporation into host tissues in sub-optimal wound conditions following ventral hernia repair.

Limb salvage after vascular reconstruction followed by tissue transfer during the Global War on Terror.

BACKGROUND: Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror. METHODS: Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared. RESULTS: From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE (P = .69). Secondary patency rates were 100% in the UE and 86% in the LE (P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE (P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain. CONCLUSIONS: Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm.

Vascularized osseous flaps and assessing their bipartate perfusion pattern via intraoperative fluorescence angiography.

BACKGROUND: Large segmental bone and composite tissue defects often require vascularized osseous flaps for definitive reconstruction. However, failed osseous flaps due to inadequate perfusion can lead to significant morbidity. Utilization of indocyanine green (ICG) fluorescence angiography has been previously shown to reliably assess soft tissue perfusion. Our group will outline the application of this useful intraoperative tool in evaluating the perfusion of vascularized osseous flaps. METHODS: A retrospective review was performed to identify those osseous and/or osteocutaneous bone flaps, where ICG angiography was employed. Data analyzed included flap types, success and failure rates, and perfusion-related complications. All osseous flaps were evaluated by ICG angiography to confirm periosteal and endosteal perfusion. RESULTS: Overall 16 osseous free flaps utilizing intraoperative ICG angiography to assess vascularized osseous constructs were performed over a 3-year period. The flaps consisted of the following: nine osteocutaneous fibulas, two osseous-only fibulas, two scapular/parascapular with scapula bone, two quadricep-based muscle flaps, containing a vascularized femoral bone component, and one osteocutaneous fibula revision. All flap reconstructions were successful with the only perfusion-related complication being a case of delayed partial skin flap loss. CONCLUSIONS: Intraoperative fluorescence angiography is a useful adjunctive tool that can aid in flap design through angiosome mapping and can also assess flap perfusion, vascular pedicle flow, tissue perfusion before flap harvest, and flap perfusion after flap inset. Our group has successfully extended the application of this intraoperative tool to assess vascularized osseous flaps in an effort to reduce adverse outcomes related to preventable perfusion-related complications.

Association of homocysteine with ventricular dilatation and brain atrophy in Parkinson's disease.

Parkinson's disease (PD) patients are treated with levodopa (L-dopa) to help stabilize their impaired motor abilities; however, L-dopa leads to increased homocysteine (Hcy) levels, which may have a deleterious effect on brain structure and function. The purpose of this study was to examine the impact of increased Hcy concentration on global brain atrophy as determined by magnetic resonance imaging in PD patients and controls. The effect of high Hcy level on ventricular dilatation (percentage of intracranial volume [%ICV]) and total tissue volume (%ICV) was examined at baseline and longitudinally at 36 months. Age, sex, education, and L-dopa duration (in PD patients) were included as covariates. Elevated Hcy levels correlated positively with ventricular dilatation (%ICV) in the whole sample (P = 0.004) and in the PD group (P = 0.008). At baseline, adults with a high Hcy level (>14 µmol/L) had higher ventricular volume (%ICV) than adults with a low Hcy level (≤ 14 µmol/L) in the whole sample (P = 0.006) and in the PD group (P = 0.03), which persisted over 36 months in both the whole sample (P = 0.004) and the PD group (P = 0.03). PD patients with high Hcy concentrations had a greater rate of ventricular enlargement (%ICV) over time compared with those with low Hcy concentration (P = 0.02). Elevated Hcy concentration was associated with increased ventricular dilatation (%ICV) in PD patients. A larger sample with a broader age range and longer follow-up is needed to establish the consequences of high Hcy level, including interactions with genetic and environmental risk factors, in PD.

From battleside to stateside: the reconstructive journey of our wounded warriors.

Recent military operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have led to further refinements of the military medical system's ability to provide advanced surgical care. The deployment of a global trauma care system has directly contributed to improved combat casualty survival rates. As a consequence of improved survivorship, a high-volume patient population of individuals having challenging multiple extremity injuries/amputations has presented to military treatment facilities. These patients present with unique mixed pattern blast injuries. Blast injuries incorporate multiple mechanisms of injury including penetrating fragmentary injury, blunt force trauma, flash burn, and overpressure wave damage. These complex injuries have furthered refinements in traditional reconstruction and facilitated early application of regenerative medicine therapies. This article summarizes information presented at the inaugural Garry Brody, MD Family Invited Lectureship presented at the 63rd California Society of Plastic Surgeons Annual.

Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction.

PURPOSE: Composite tissue defects in the head and neck region present unique challenges. Definitive head and neck reconstruction of these cases is often complicated by complex 3-dimensional defects that may require multiple flap or chimeric flap procedures. These advanced techniques can have serious repercussions should poor perfusion of the flap cause flap failure, which can be devastating. MATERIALS AND METHODS: A retrospective review was completed for those complex reconstructions using free tissue transfers and fluorescent indocyanine green angiography (Lifecell SPY Elite imaging, Lifecell Corporation, Bridgewater, NJ) at Walter Reed National Military Medical Center over a 24-month period. Data analyzed included flap type (myocutaneous, osteocutaneous, or fasciocutaneous), flap success and failure rates, and complications. These also were compared with data from the institution before the study period and the incorporation of SPY technology. RESULTS: Sixty-one free flaps, including 11 head and neck flaps, were performed. The head and neck flaps included 1 latissimus, 3 gracilis, 1 vastus lateralis, 4 anterior lateral thigh, and 2 fibular flaps. The overall success rate was 98.4%; 1 flap was lost (1.6%) and 2 flaps developed partial flap necrosis (3.3%). Where SPY Elite was used, there was no unpredicted partial flap necrosis. The only total flap loss was related to a hypercoagulable condition. CONCLUSIONS: Free tissue transfer can be technically challenging, especially in complex head and neck reconstruction. An algorithmic approach using SPY Elite imaging aids in pedicle location, angiosomal assessment, anastomotic flow visualization, and cutaneous and osteocutaneous flap perfusion assessment. This objective tool can assist the reconstructive surgeon in avoiding perfusion-related complications and total and partial flap losses, thus improving patient outcomes.

Sequential free tissue transfers for simultaneous upper and lower limb salvage.

BACKGROUND: The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. METHODS: All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free-flap limb salvage cohorts. RESULTS: Seventy-four free flap limb salvage cases were performed over the 10-year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). CONCLUSIONS: The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients.

Surgical management of craniofacial neurofibromatosis type 1 associated tumors.

Neurofibromatosis type 1 is a rare, autosomal dominant disorder than can present with varying degrees of disfigurement depending on the associated tumor extent and location. Surgical resection is considered the most effective management of these typically benign tumors, indicated when symptoms include pain, extreme deformity, or interference with normal physical function. Giant tumors of the craniofacial region present particular difficulty due to the size of the post-resection wound deficit and the high risk surgery poses to function such as vision and facial animation in this region. Strategies of management are discussed.

Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization and Medical Readiness for Military Patients.

INTRODUCTION: Access to surgical care for gender-affirming surgery (GAS) has been a persistent challenge within the DoD due to long waiting lists, strict insurance requirements, and surgeon/subspecialty scarcity. These issues were magnified during the COVID-19 pandemic response, as limited resources led to postponement of "elective" surgeries. To remedy this, our center organized a multidisciplinary collaboration to perform simultaneous GAS. This model is necessary to optimize the quality-of-life and medical readiness for a particularly marginalized population within the U.S. Military who now constitute roughly 1% of all active duty personnel. In addition, one-stage surgery provides a feasible solution to streamlining care and decreasing DoD personnel health care costs. MATERIALS AND METHODS: We present a case describing successful multidisciplinary surgical management of a transgender woman desiring multiple GASs. We include a comparative, cost-benefit analysis to emphasize the advantages of single-stage over multistage surgeries. RESULTS: Our patient is a 24-year-old active duty transgender female who underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Our patient was discharged on post-operative day 1 and had an uneventful recovery without complications. Keys to successful implementation included the judicious, coordinated use of local analgesia as well as the organization of separate operating room bedside tables and scrub techs for each team. Total convalescent leave time and temporary profile duration were reduced by 50% relative to the staged approach: 4 weeks and 3 months versus 8 weeks and 6 months, respectively. Of note, anesthesia provider fees total ∼$8,213 when surgeries are performed as three separate events. For one-stage surgery, anesthesia fees amount to only $1,063 (assuming ∼10 hour anesthesia time with a CRNA provider). CONCLUSIONS: Our case study demonstrates that one-stage multidisciplinary surgery can be accomplished without added risk to the patient. Judicious surgical planning, including having surgeons operating at the same time, reduces operative time and provides for efficient operating room utilization. Simultaneous GAS is an effective approach to improve access to surgical care for transgender patients. A single anesthetic enables patients to achieve their surgical goals sooner and to lessen their overall recovery time. This allows service members to return to duty sooner, supporting the Defense Health Agency mission to ensure a medically-ready force. This model should become the standard within MTFs across the DoD, as it promotes improved quality-of-life for patients, decreases personnel costs, and ensures medical readiness.

Ventricular dilatation and brain atrophy in patients with Parkinson's disease with incipient dementia.

Age-related ventricular enlargement is accelerated in Alzheimer's disease, but its relationship to cognitive decline in Parkinson's disease is less clear, even though dementia is common in Parkinson's disease. Our goals were to determine if greater enlargement of the ventricles and gray or white matter atrophy occurred in Parkinson's disease patients developing cognitive decline. Older nondemented patients with Parkinson's disease (33) and age- and sex-matched controls (39) were recruited and prospectively assessed for the development of significant cognitive decline over 36 months. Magnetic resonance imaging was obtained every 18 months, and ventricular volume and total brain gray and white matter volumes were measured using reliable segmentation of T1-weighted volumetric scans. Subjects with incidental intracranial abnormalities, an atypical course, and stroke as well as dropouts were excluded from a cohort of 52 patients and 50 controls. Among 33 patients and 39 controls, 10 patients and 3 controls developed significant cognitive impairment or dementia. Ventricular change and Parkinson's disease status were significantly associated with dementia. Ventricular change was significantly correlated with change in Mini-Mental Status Examination in the Parkinson's disease with dementia group (r = 0.87, P = .001). Gray matter atrophy was greater in Parkinson's disease with dementia, with similar change over time in both Parkinson's disease and Parkinson's disease with dementia. White matter volumes were not significantly different between Parkinson's disease and Parkinson's disease with dementia; however, the decrease over time might be greater in Parkinson's disease with dementia. Ventricular dilatation occurs early in the course of significant cognitive decline in patients with Parkinson's disease, possibly reflecting both cortical gray and white matter loss.

Selective effects of aging on brain white matter microstructure: a diffusion tensor imaging tractography study.

We examined age-related changes in the cerebral white matter. Structural magnetic resonance images (MRIs) and diffusion tensor images (DTIs) were acquired from 69 healthy subjects aged 22-84 years. Quantitative DTI tractography was performed for nine different white matter tracts to determine tract volume, fractional anisotropy (FA), mean diffusivity (MD), axial, and radial diffusivities. We used automated and manual segmentation to determine volumes of gray matter (GM), white mater (WM), cerebrospinal fluid (CSF), and intracranial space. The results showed significant effects of aging on WM, GM, CSF volumes, and selective effects of aging on structural integrity of different white matter tracts. WM of the prefrontal region was the most vulnerable to aging, while temporal lobe connections, cingulum, and parieto-occipital commissural connections showed relative preservation with age. This study was cross-sectional, and therefore, additional longitudinal studies are needed to confirm our findings.

Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care. SUMMARY: Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.

The assessment of cervical foramina with oblique radiographs: the effect of film angle on foraminal area.

STUDY DESIGN: Radiographic evaluation of cadaveric cervical spine specimens. OBJECTIVE: Assess reliability and reproducibility of foraminal dimensions obtained from cervical radiographs of varying obliquity and determine optimal angles for visualizing foramina at each cervical spine level. SUMMARY OF BACKGROUND DATA: Oblique radiographs may be considered to assess cervical foraminal dimensions and are generally obtained 45 degrees from the anteroposterior (AP) orientation. Previous reports have suggested that foraminal area observed on these radiographs may be influenced by changes in obliquity so that certain film angles may be better suited for accurately assessing foramen size, depending on which level is being evaluated. METHODS: Radiographs of 4 human cadaveric cervical spines were obtained at 5-degree increments from 20 to 70 degrees relative to AP orientation, using both left and right sides of each specimen. Foraminal area was estimated by measuring height and width of each foramen and also with a freehand area measurement tool. Reliabilities of both methods were calculated. At each level, foraminal area was plotted against film angle and quadratic best-fit curves were used to determine the maximum area observed and the optimal angle of obliquity for assessment. RESULTS: Assessment of foraminal area using the height and width values was associated with good interobserver reliability, whereas the freehand method exhibited excellent reliability. The optimal film angles for calculating foraminal area increased from 46.3 degrees for C2-C3 to 56.1 degrees for C7-T1. The ideal film angle that minimized the overall error of measurement across the entire cervical spine was estimated to be 52.4 degrees. CONCLUSIONS: Optimal angles for visualizing lower cervical foramina are larger than those for upper cervical spine. To minimize overall loss of foraminal area throughout the entire cervical spine, oblique cervical radiographs should be obtained at an angle of approximately 52 degrees from the AP orientation.

Relative Tissue Oxygenation and Temperature Changes for Detecting Early Upper Extremity Skin Ischemia.

The authors' purpose was to determine whether there are reliable noninvasive methods of assessing upper extremity ischemia regardless of skin pigmentation. The authors conducted a study of healthy subjects classified based on skin pigmentation using the Fitzpatrick scale, the von Luschan color scale, and self-described race (two Hispanics, three Caucasians, and four African Americans). A surface temperature probe and a near-infrared spectroscopy monitor were placed on the posterior interosseous artery skin territory. Temporary upper limb ischemia was induced by tourniquet insufflation. Readings from both devices were taken at baseline and every 15 seconds for a total of 10 minutes of ischemia. During tourniquet insufflation, the authors found a reliable decrease in tissue oxygenation measured by near-infrared spectroscopy in all subjects and no significant change in temperature readings for any subjects. There was an average decrease of 19 percent in tissue oxygenation using near-infrared spectroscopy, with measurements on average starting at 77 percent and ending at 57 percent. There was no significant difference in the change in near-infrared spectroscopy oxygenation between participants with Fitzpatrick skin types 3, 4, and 5 or when participants were grouped into Fitzpatrick skin type less than or equal to 3 versus greater than 3, or when grouped into Fitzpatrick skin type less than or equal to 4 versus greater than 4. There was also no significant difference in participants grouped into von Luschan scores less than or equal to 20 versus greater than 20. In this healthy subjects study, near-infrared spectroscopy rapidly identified ischemia in all cases, whereas skin surface temperature did not. Near-infrared spectroscopy may be a reliable way of noninvasively monitoring for ischemia regardless of skin pigmentation degree. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.

Top Surgery in Transgender Men: How Far Can You Push the Envelope?

BACKGROUND: The authors present their grading scale and the outcomes of the largest cohort of top surgery published to date. Application of this grading system can help determine which patients will benefit from a subcutaneous mastectomy with free nipple graft versus a circumareolar technique, with the primary endpoint being need for aesthetic revisions. METHODS: The authors reviewed their database of transgender males who underwent bilateral mastectomy between 2006 and 2015. Data collected included age, body mass index, American Society of Anesthesiologists class, smoking, diabetes, testosterone use, months of social transition, technique used, postoperative complications, and need for revision. Two techniques were used, circumareolar incision and free nipple graft technique. RESULTS: Between 2006 and 2015, 1686 consecutive mastectomies were performed on 843 patients. Of those, 548 patients were excluded because of inadequate follow-up. Of the 295 included, 109 were treated using a circumareolar incision and 186 were treated using a free nipple graft technique. There was no statistically significant difference in complications between the two groups; however, there was a statistically significant difference in the rate of aesthetic revisions in the grade 2B circumareolar incision group (34 percent versus 8.8 percent). CONCLUSIONS: The authors' outcomes are comparable to the literature, and demonstrate that these procedures can safely be performed in an outpatient setting. The authors' grading scale classifies patients and helps the surgeon select a surgical technique. The authors show a statistical difference in rates of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.