Prospective Analysis of the Greater Occipital Nerve Location in Patients Undergoing Occipital Nerve Decompression.

BACKGROUND: Migraine surgery and onabotulinumtoxinA injections aim to deactivate neurovascular trigger points implicated in chronic headaches. The greater occipital nerve (GON) is a common trigger point. The depth of this nerve has not been previously described. The purpose of this study was to report the intraoperative location, including depth, of the GON in human subjects undergoing migraine surgery. METHODS: We reviewed records of patients who underwent GON decompression by a single surgeon. Intraoperative measurement of the GON location lateral to midline, inferior to the occipital protuberance, and deep to the skin was collected for 2 previously described positions: where GON (a) enters, "point #2," and (b) exits, "point #3," the semispinalis muscle as it travels from deep to superficial (Plast Reconstr Surg. 2010;126:1563-1572; Plast Reconstr Surg. 2004;113:693-697). RESULTS: Thirty-four subjects (60 nerves) were included. The mean depths of the GON were 20 mm (SD, 4) at point no. 3 and 30 mm (SD, 6) at point no. 2. In 26 subjects who underwent bilateral surgery, there was a difference between right and left nerve position lateral to midline at point no. 3 (P = 0.008). Female sex (P = 0.014) and body mass index of 29 kg/m or less (P < 0.001) were associated with a more superficial GON position. CONCLUSIONS: Knowledge of the GON depth (eg, mean of 20 mm where it emerges from the semispinalis muscle) may improve accuracy of procedural treatments for migraines. When performing bilateral interventions, nerve position may differ between sides, particularly with respect to lateral distance from midline. Differences in this study compared with previous anatomic studies may reflect the use of live subjects in a prone position compared with cadaver specimens.

Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study.

BACKGROUND: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. METHODS: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. RESULTS: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. CONCLUSIONS: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Aggressive Digital Papillary Adenocarcinoma: Case Report of a Positive Sentinel Lymph Node and Discussion of Utility of Sentinel Lymph Node Biopsy.

Aggressive digital papillary adenocarcinoma (ADPA) is an uncommon eccrine sweat gland tumor of the distal extremities that is associated with a high rate of local recurrence and distant metastasis. Current opinion suggests that sentinel lymph node evaluation should be done for high-risk tumors where lymph node spread is a concern. Despite documented spread to regional lymph nodes, information on sentinel lymph node status in ADPA is reported infrequently, with only 1 documented case of positive findings. We report on a case of ADPA of the right long finger where sentinel lymph node biopsy was done and positive for metastases in the axilla, resulting in a subsequent completion lymphadenectomy. To determine the benefit of sentinel lymph node biopsy in ADPA, there is a need for more cases of sentinel lymph node evaluation along with data on local recurrence and distant metastasis in those with positive and negative findings.

Free flap monitoring using an implantable anastomotic venous flow coupler: Analysis of 119 consecutive abdominal-based free flaps for breast reconstruction.

PURPOSE: The purpose of this study is to evaluate the use of the venous anastomotic Flow Coupler in monitoring free flaps used for breast reconstruction in a consecutive series of patients. METHODS: Retrospective data were collected on patients undergoing free flap breast reconstruction from May 2012 to March 2014. The venous anastomotic Flow Coupler was used in the first 85 flaps and a non-flow Coupler with clinical and external Doppler monitoring alone in the subsequent 34 flaps. Data collected included patient age, BMI, prior radiation, flap type, intra- and postoperative Flow Coupler events, along with rates of flap take back, salvage, and failure. Proportion data were compiled and statistically analyzed. RESULTS: One hundred nineteen consecutive abdominal based breast reconstruction free flaps were performed. The overall flap failure rate was 4.2% (4.7% Flow Coupler; 2.9% in non-flow Coupler; P = 1.0). The Flow Coupler demonstrated 100% sensitivity in the intra- and postoperative settings. A positive predictive value of 36% was noted intraoperatively which was significantly higher compared to the non-flow Coupler group (P = 0.015). Vessel thrombosis occurred in 17.6% of Flow Coupler flaps, which was significantly higher when compared to the non-flow Coupler (2.9%; P = 0.038). CONCLUSIONS: The Flow Coupler is a sensitive method to confirm patency of a microsurgical anastomosis. However, there is a high false positive rate in both the intraoperative and postoperative settings resulting in frequent intraoperative maneuvers to amend the cause of signal loss. Additionally, the Flow Coupler resulted in significantly more vascular thrombotic events when compared to the non-flow Coupler.

Evaluating current functional airway surgery during rhinoplasty: a survey of the American Society of Plastic Surgeons.

BACKGROUND: Despite numerous reports outlining technical modifications in rhinoplasty, few publications discuss the importance of the perioperative assessment and surgical management of the nasal airway. This study's objective is to increase awareness regarding the functional aspects of rhinoplasty surgery and to encourage surgeons to incorporate functional airway management into their rhinoplasty practice. METHODS: A web-based survey was given to all members of the American Society of Plastic Surgeons (ASPS). Survey results were analysed to determine if surgeons' experience, annual rhinoplasty volume, or postgraduate training affected their results. The relationship between surgeon satisfaction with the outcome of the airway management and the frequency of performing an inferior turbinate reduction was investigated. RESULTS: Of the 4,383 listed ASPS members, 671 (21%) completed the web-based survey. Surgeons who performed a preoperative internal nasal exam were more satisfied with their results (p = 0.016) and report lower rates of postoperative nasal airway obstruction (p = 0.054). Inferior turbinate reduction did correlate to postoperative satisfaction with the nasal airway (p < 0.001). Overall, 85% of respondents were satisfied with their management of the nasal airway and 87% of respondents agreed that there is a need for more instructional courses on this topic. CONCLUSION: There is considerable variation in the results and techniques of assessment and treatment of the nasal airway. Rhinoplasty volume and inferior turbinate reduction are associated with surgeon satisfaction of management of the nasal airway. Functional airway considerations should be incorporated into routine rhinoplasty training, assessment, and treatment. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Major Histocompatibility Complex-Matched Arteries Have Similar Patency to Autologous Arteries in a Mauritian Cynomolgus Macaque Major Histocompatibility Complex-Defined Transplant Model.

Background Arterial bypass and interposition grafts are used routinely across multiple surgical subspecialties. Current options include both autologous and synthetic materials; however, each graft presents specific limitations. Engineering artificial small-diameter arteries with vascular cells derived from induced pluripotent stem cells could provide a useful therapeutic solution. Banking induced pluripotent stem cells from rare individuals who are homozygous for human leukocyte antigen alleles has been proposed as a strategy to facilitate economy of scale while reducing the potential for rejection of induced pluripotent stem cell-derived transplanted tissues. Currently, there is no standardized model to study transplantation of small-diameter arteries in major histocompatibility complex-defined backgrounds. Methods and Results In this study, we developed a limb-sparing nonhuman primate model to study arterial allotransplantation in the absence of immunosuppression. Our model was used to compare degrees of major histocompatibility complex matching between arterial grafts and recipient animals with long-term maintenance of patency and function. Unexpectedly, we (1) found that major histocompatibility complex partial haplomatched allografts perform as well as autologous control grafts; (2) detected little long-term immune response in even completely major histocompatibility complex mismatched allografts; and (3) observed that arterial grafts become almost completely replaced over time with recipient cells. Conclusions Given these findings, induced pluripotent stem cell-derived tissue-engineered blood vessels may prove to be promising and customizable grafts for future use by cardiac, vascular, and plastic surgeons.

Surgical Education Module Improves Operative Proficiency in Endoscopic Carpal Tunnel Release: A Blinded Randomized Controlled Trial of Trainees.

OBJECTIVE: The purpose of this study is to evaluate whether an interactive endoscopic carpal tunnel release (ECTR) surgical education module can improve knowledge of surgical indications and improve procedural competency. DESIGN: An ECTR education module was developed and trainees at various level of training were enrolled and randomized to surgical module and nonmodule (control) groups. Subjects were instructed that they would be the primary surgeon performing an ECTR. A written assessment was administered before and after module completion or independent case preparation to test comprehension of the procedure. The senior author evaluated each subject's intraoperative performance using a 5-point scoring system. Statistical analysis was performed using chi-square and paired t-tests. SETTING: This study took place at a tertiary care hospital at the University of Wisconsin. RESULTS: In all, 30 subjects were tested (15 surgical module and 15 nonmodule). There were no differences in prepreparation test scores between groups. Postpreparation test scores following use of the module were significantly higher compared to the nonmodule group. The average operation performance scores for the surgical module group and nonmodule group were 96% and 82%, respectively. The surgical module group performed significantly better on all operative steps except for dressing application. Surgical module subjects without prior ECTR experience (n = 7) had operative scores that were significantly higher than those for nonmodule subjects without previous ECTR experience (n = 8) (95% vs. 75%). There was no difference in operative scores between surgical module subjects with no prior experience (n = 7) and nonmodule subjects who had performed at least 1 prior case (n = 7) (95% vs. 89%). CONCLUSIONS: The use of an ECTR surgical education module demonstrates a significant benefit in ECTR-naïve subjects. When compared to subjects with previous ECTR experience, ECTR-naïve subjects trained using the surgical module demonstrate better familiarity with the equipment and equivalent performance of the procedure.

Repair of a Large Ventral Hernia in a Rhesus Macaque (Macaca mulatta) by Using an Abdominal Component Separation Technique.

Here we present a 32-y-old rhesus macaque (Macaca mulatta) with a large recurrent ventral incisional hernia. The initial surgery included midline celiotomy for treatment of endometriosis, in which the animal developed a hernia that was repaired with interposition of mesh. Hernia recurrence at 1 y resulted in a defect measuring 7 × 13 cm, with loss of abdominal domain. Skin breakdown was noted with areas of exposed mesh through the skin with associated acute on chronic infection. Clinically, the animal was lethargic, not eating, and failing to thrive. The present surgical treatment included midline celiotomy, removal of mesh, and attempted primary fascial closure. Due to the large defect and high tension, the fascia could not be closed. To facilitate closure, abdominal component separation technique was used and consisted of skin and subcutaneous dissection, external oblique muscle release, and dissection between the external and internal oblique musculature. This technique allowed for primary fascial closure and resection of excess diseased skin. A piece of polypropylene mesh was placed in a sublay fashion to reinforce the primary fascial closure. The animal tolerated the procedure well and has demonstrated steady weight gain, with no recurrence at 12 mo. Large ventral abdominal hernia defects in after surgery or trauma in NHP can present reconstructive challenges to veterinary surgeons. Failure to achieve a dynamic, low-tension closure can result in hernia recurrence, necessitating additional operations. Abdominal component separation is not commonly used in veterinary surgery and may be a helpful tool in cases of difficult abdominal reconstructions.

A Prospective Randomized Trial Comparing the Effects of Lidocaine in Breast Reduction Surgery.

BACKGROUND: Use of dilute epinephrine tumescent solution in breast reduction surgery has been shown to significantly decrease operative blood loss without increasing perioperative complications. Lidocaine is commonly added to epinephrine to decrease postoperative pain. Evidence supporting this practice, however, is limited, and lidocaine toxicity has been reported. METHODS: With institutional review board approval, patients undergoing bilateral breast reduction surgery were assigned to receive either tumescent saline solution with epinephrine (1:1 million) (group 1), or tumescent saline solution with epinephrine (1:1 million) and lidocaine (0.05%) (group 2). Tumescent solution (500 ml) was infiltrated just before skin incision. Wise pattern reduction with an inferior pedicle was used in all cases. A nurse in the postanesthesia care unit documented immediate postoperative pain and intravenous narcotic use. Patients used a survey to record postoperative pain, nausea/vomiting, and narcotic use for the first 24 hours. Results were analyzed using analysis of variance and logistic regression models. RESULTS: Forty consecutive patients were enrolled (20 in each group). There was no statistical difference between groups 1 and 2 in total intravenous narcotic use (0.89 versus 0.55; p = 0.10), 24-hour narcotic use (32.19 versus 29.47; p = 0.71), peak pain scores both in the postanesthesia care unit (5.47 versus 4.47; p = 0.24) and 24 hours postoperatively surgery (6.44 versus 6.68; p = 0.78), and 24-hour nausea/vomiting counts [group 1, OR, 1.11 (p = 0.87); group 2, OR, 1.87 (p = 0.51)]. There were no hospital admissions in either group. CONCLUSIONS: The addition of lidocaine to tumescent solution does not significantly affect postoperative pain following breast reduction surgery. Considering potential risks and added costs, this practice may not be of benefit. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Quantitative Assessment of Tension Reduction at the Midline Closure During Abdominal Component Separation.

BACKGROUND: Abdominal component separation is used commonly for closure of midline abdominal wounds. The value of each step in reducing tension has not been studied. Our aim was to test whether component separation decreases tension in the midline closure and to quantify the value of each procedural step. STUDY DESIGN: Tension required to bring the rectus muscle to midline was measured using tensiometry after subcutaneous dissection (step 1), external oblique muscle release (step 2), separation of the internal and external oblique muscles (step 3), and internal oblique muscle release (step 4). Measurements were taken in the upper, middle, and lower thirds of the abdominal midline. Distance to midline was also measured after each surgical step. Tension (measured as percent change) and distance were analyzed using Student's t-test with significance set at p < 0.05. RESULTS: In 41 hemi-abdominal defects, tension decreased in middle, upper, and lower thirds of the abdomen by 22.5%, 24.3%, and 34.8% after step 1; 33.4%, 31.8%, and 39.8% after step 2; 26.5%, 22.2%, and 27.4% after step 3; and 33.2%, 28.2%, and 23.5% after step 4. Mean distance change was 0.97 cm, 1.97 cm, 2.22 cm, and 2.59 cm after steps 1 to 4, respectively. CONCLUSIONS: This study shows through a quantitative measure of tension that all steps of the component separation procedure decrease wound tension to variable degrees, with the release of the external and internal oblique muscles being the more effective steps. An internal oblique release is a useful and simple adjunct to the classical component separation procedure.

Making Master Surgeons Out of Trainees: Part I. Teaching Surgical Judgment.

The training of competent and ethical plastic surgery residents has become more difficult, as surgeons face increasing clinical and research demands, concern for medicolegal liability, and pressure to increase efficiency to decrease health care expenditures. The resulting variation in operative experience among plastic surgery trainees exemplifies the need for educational reform to accommodate change. Although the Accreditation Council for Graduate Medical Education has mandated a transition to competency-based training, and state-of-the-art technologies in surgical simulation are being developed to improve operative skills, the construction of a system to teach and assess operative judgment is deficient and should be thoughtfully created and implemented. Established educational methods and curriculums can be used in this effort and include apprenticeship operative teaching, surgical simulation, morbidity and mortality conferences, and resident clinics. The first step in this effort is to require trainees to make decisions, communicating their judgments and recommendations using language that demonstrates clear thinking and thoughtful analysis. For faculty, this means carving out dedicated preoperative teaching time in addition to efficient use of intraoperative time and sharing of postoperative outcomes. For programs, this means developing metrics to evaluate progress and build procedure-specific simulations. The goal should be not just to settle for training safe and ethical surgeons but to produce masterful surgeons with mature judgment.

A Multi-Layered Needle Injection Simulator.

Insuring correct needle location is crucial in many medical procedures. This can be even more challenging for physicians injecting in a new location for the first time. Since they do not necessarily know how the tissue is supposed to feel, finding the correct location and correct depth can be difficult. In this study we designed a simulator for training needle injection. The simulator was fabricated to give a realistic feeling of injecting Botox® in the temporalis and the semispinalis muscles as part of migraine treatment. In addition the simulator provided real-time feedback of correct needle location. Nine residents and medical students evaluated the simulator. They made several errors that were corrected real time using the real time feedback provided. They found the simulator to be very useful and that the training significantly improved their confidence. The methods described in this study can easily be implemented for developing needle injection simulators for other anatomical locations.

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon.

BACKGROUND: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. METHODS: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. RESULTS: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. CONCLUSION: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.

Microsurgical Technique Modifications: Practical Tips for Improving Precision.

Supplemental Digital Content is available in the text.

A systematic review of distraction osteogenesis in hand surgery: what are the benefits, complication rates, and duration of treatment?

BACKGROUND: This work analyzes the utility of distraction osteogenesis as a surgical option for the management of acquired and traumatic hand deformities through a systematic review of the published literature. METHODS: A PubMed search for articles reporting results of distraction osteogenesis in the hand was performed. Data collected included age, sex, cause, bone distracted, latency period, distraction rate, consolidation period, treatment time, length gained, and complications. Proportion data variables were compared using the chi-square test. A meta-analysis was also performed to assess the size effect of variables on complication development. RESULTS: Thirty articles (424 distractions) met inclusion criteria. The average length gained from distraction was 2.2 cm; the average total treatment time was 116 days; the average complication rate was 26.4 percent. Proportion analysis, including all articles, showed that congenital cause had significantly fewer complications compared with traumatic cause (p = 0.0129). A lower complication rate in pediatric patients compared with adults approached but did not reach significance (p = 0.0507). Studies that underwent meta-analysis, including only articles comparing both variables of interest, were homogeneous (I < 25) and without publication bias (Kendall's tau p > 0.05 and symmetric funnel plot). None of the variables analyzed by meta-analysis had a significant odds ratio for complication development (p > 0.05). CONCLUSION: Despite distinct advantages, distraction osteogenesis is associated with a long duration of treatment and high complication rates, particularly in adults and in posttraumatic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.