Forked Paramedian forehead flap combined with nasolabial flap for pre-radiation coverage of exposed maxilla in the Total Rhinectomy patient.

Total rhinectomy is ontologically necessary for large and locally invasive carcinomas of the nasal cavity owing to the complex three-dimensional structure of the nose. Reconstruction options include singular or combined options of local tissue rearrangement, free flap reconstruction, and prosthetic reconstruction which may be delayed in the setting of post-ablative radiation therapy. If significant bony exposure is present prior to radiation, there is a substantial risk of osteoradionecrosis and the ensuing sequalae. In these cases, coverage of the bony defect may be advantageous prior to radiation and final reconstructive treatment. We present a case of a total rhinectomy defect for squamous cell carcinoma in a patient who had significant bony exposure prior to radiation which was resurfaced with a combined forked paramedian flap and nasolabial flap. The patient went on to be treated with a full course of radiation and had planned for a post-treatment nasal prosthesis.

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points.

BACKGROUND: With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery. METHODS: Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups. RESULTS: The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74). CONCLUSIONS: To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

The Cost of Applying to Integrated Plastic Surgery Residency.

Integrated plastic surgery remains one of the most competitive specialties within the National Resident Matching Program. Although the burden of applying to surgical residencies has been studied, the literature lacks data specific to integrated plastic surgery applicants. This study reports the current total cost, along with the outcomes of applying to and interviewing for integrated plastic surgery residency. METHODS: A survey was sent to applicants in the 2018-2020 integrated plastic surgery application cycles. Survey questions focused on applicant demographics and home medical school characteristics, application processes, interview attendance, interview cost, and applicant financing. Comparative and regression analyses were performed on survey responses. RESULTS: The survey was distributed to 493 applicants. An estimated 245 (49.7%) applicants responded. On average, applicants applied to 68.3 ± 16.4 (mean ± SD) programs, received 17.6 ± 11.4 interview invites, and attended 12.6 ± 5.7 of the interviews they received. On average, each applicant spent a total of $6690 ± $4045 during the interview season, with individual interviews costing $531. Residency programs providing financial assistance supplemented $73 ± $64 per interviewee, corresponding to 13.7% of per-interview cost. To cover costs, 33.8% of applicants sought additional funding, and 30.7% of applicants stated that they had supplemental income, with an average monthly supplemental income of $1971 ± $1558. CONCLUSIONS: This study quantifies the recent total and per-interview cost of applying to integrated plastic surgery residency. It also identifies the importance of cost to applicants and how the cost burden of residency applications is supported.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques.

SUMMARY: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.