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.

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.

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.

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.

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.

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.

The 5Cs of Consultation: Training Medical Students to Communicate Effectively in the Emergency Department.

BACKGROUND: Effective communication is critical for health care professionals, particularly in the Emergency Department (ED). However, currently, there is no standardized consultation model that is consistently practiced by physicians or used for training medical graduates. Recently, the 5Cs of Consultation model (Contact, Communicate, Core Question, Collaborate, and Close the Loop) has been studied in Emergency Medicine residents using simulated consultation scenarios. OBJECTIVE: Using an experimental design, we aimed to evaluate the efficacy of the 5Cs consultation model in a novel learner population (medical students) and in a "real time and real world" clinical setting. METHODS: A prospective, randomized, controlled study was conducted at eight large, academic, urban, tertiary-care medical centers (U.S. and Canada). Intervention involved two experimental groups (asynchronous and live training) compared to a baseline control group. All participants placed up to four consult phone calls. A senior physician observed and assessed each call using a preapproved 5Cs checklist and a Global Rating Scale (GRS). RESULTS: Participants who received training (asynchronous or live) scored significantly higher on the 5Cs checklist total and GRS than the control group. Both training methods (asynchronous and live) were equally effective. Importantly, learning gains were sustained as students' 5Cs checklist total and GRS scores remained consistently higher at their second, third, and fourth consult (relative to their first consult). At posttest, all participants reported feeling more confident and competent in relaying patient information. CONCLUSION: Medical students can be trained to use the 5Cs model in a timely, inexpensive, and convenient manner and increase effectiveness of physician consultations originating from the ED.

Milestones Contributing to the Evolution of Craniofacial Surgery.

Craniofacial surgery (CFS) has a rich history of collaboration with a wide variety of surgical and nonsurgical specialties. This has resulted in a large volume of publications across this spectrum of subspecialties cataloging the advancements across the field. The authors aim to analyze the characteristics of the most cited articles in CFS. A literature search was performed using the Thomson/Reuters Web of Knowledge database to identify the top 50 most cited articles in CFS. The articles were analyzed for journal distribution, total citations, year of publication, citations per year, number of authors, type of article, institution, departmental affiliation, national affiliation, and top contributors. The articles were extracted from an assortment of 21 journals. The number of citations per article ranged from 115 to 1092 (average of 185). Forty-eight percent of articles were published in the 1990s, and 22% in the 2000s. The average number of years since publication until the present time was 21.34 (range 6-45 y). The most cited article (1092 citations and 52 citations/y) was an article by McCarthy et al on human mandible lengthening via gradual distraction. Departmental distribution indicated that the majority were attributable to departments of Plastic and Reconstructive Surgery for 21 articles (42%). Twenty articles were categorized under cranial defect/bone substitutes, 12 under craniosynostosis, 7 under surgical modeling, 6 under distraction osteogenesis, and the remaining 5 under other. These articles qualitatively represent important milestones in CFS. This study affirms the potential value of "number of citations" as a meaningful metric when assessing the importance of an article within CFS.

Microsurgical Anatomy of the Terminal Hypoglossal Nerve Relevant for Neurostimulation in Obstructive Sleep Apnea.

BACKGROUND: Neurostimulation of the hypoglossal nerve has shown promising results in the treatment of obstructive sleep apnea. This anatomic study describes the detailed topography of the hypoglossal nerve's motor points as a premise for super-selective neurostimulation in order to optimize results and minimize the risk of complications related to main nerve trunk manipulation. METHODS: Thirty cadaveric hypoglossal nerves were dissected and characterized by number of branches, arborization pattern, and terminal branch motor point location. For each motor point, the distance to cervical midline (x axis), distance to posterior aspect of the symphysis (y axis), and depth from the plane formed by the inferior border of symphysis and anterior border of hyoid (z axis) were recorded. RESULTS: The average number of distal branches for each hypoglossal nerve was found to be 9.95 ± 2.28. The average number of branches per muscle was found to be 3.3 ± 1.5 for the hyoglossus muscle, 1.8 ± 0.9 for the geniohyoid muscle, and 5.0 ± 1.6 for the genioglossus muscle. It was found that branches to the genioglossus and geniohyoid muscles were located closer to midline (relative lengths of 0.19 ± 0.07 and 0.19 ± 0.05, respectively) while hyoglossus branches were located more laterally (0.38 ± 0.10 relative length). On the y-axis, the branches to the genioglossus were the most anterior and therefore closest to the posterior symphysis of the mandible (relative length of 0.48 ± 0.11), followed by the geniohyoid (0.66 ± 0.09), and the hyoglossus (0.76 ± 0.16). The branches to the geniohyoid were the most superficial (relative length of 0.26 ± 0.06), followed by the genioglossus (0.36 ± 0.09), and finally, the hyoglossus branches (0.47 ± 0.11), which were located deeply. CONCLUSION: A topographical map of the hypoglossal nerve terminal motor points was successfully created and could provide a framework for the optimization of the neurostimulation techniques.

Syndromic lipomatosis of the head and neck: a review of the literature.

INTRODUCTION: Patients with syndromic causes of lipomatosis of the head and neck, although rare, often present late in the course of the disease in a myriad of ways, including concomitant airway obstruction, severe functional limitations, and/or significant cosmetic defects. The goal of this report was to review the literature and present a concise overview of the major syndromes causing lipomatosis of the head and neck. METHODS: A literature search was performed to gather information on syndromic lipomatosis of the head and neck region. PubMed was searched for the following conditions: Familial multiple lipomatosis (FML), multiple symmetrical lipomatosis (MSL), congenital infiltrating lipomatosis of the face (CIL-F), and Nasopalpebral lipoma-coloboma syndrome (NLCS). Data gathered included results of surgical cases of the head and neck region. RESULTS: A total of 48 reports comprising 172 cases of syndromic lipomatosis of the head and neck region were deemed eligible for review. Eighty-five percent of patients were male with an average age of 35 years. Seventy-four percent of cases appeared in the neck region, whereas 23 % presented in the face and scalp. 89 % of cases were treated with surgical excision, with 11 % of cases treated with liposuction. The most common complications were hematoma and seroma in MSL, recurrence in FML, neuropraxia in CIL-F, and mild telecanthus in NLCS. CONCLUSIONS: Syndromic causes of lipomatosis are generally benign in nature but difficult to control long term. Because these conditions include frequent recurrence and subsequent difficulty in clearing the disease, the authors advocate early and aggressive surgical excision of syndromic lipomatosis. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

The "weekend effect" in plastic surgery: analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010.

BACKGROUND: Body contouring operations are a quickly becoming the most commonly performed operations by American plastic surgeons, mirroring the increase in bariatric surgery in the US over the last decade. Despite previous studies showing worse patient outcomes on weekend admissions for non-emergent cases (spine, breast, and hernia), there is no comparative data reported regarding body contouring procedures. OBJECTIVE: The authors aimed to determine whether body contouring surgery results in worse outcomes when performed on weekends versus weekdays. METHODS: A serial cross-sectional study of body contouring patients was performed using the Nationwide Inpatient Sample database from 2000 to 2010. Data were gathered using international classification of diseases, ninth revision codes for liposuction and reduction of adipose tissue (86.83) for weekday and weekend admissions, including demographics, hospital charges, and patient outcomes. RESULTS: A total of 50,346 hospital admission cases of inpatient body contouring were examined over the 11-year period, 98% of which were on a weekday. When compared to weekday admissions, weekend admissions were associated with a statistically significant increase in hospitalization costs ($35,481, p < 0.000) and in hospital length of stay (5.68 days, p < 0.000). Mortality rates were found to be higher on weekend admissions (3.7%) versus weekdays (0.5%) as well. CONCLUSIONS: Although outcomes are multifactorial, in body contouring patients, weekday admission is associated with favorable outcomes in terms of length of stay and hospital charges. LEVEL OF EVIDENCE: 4 Risk.

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.

The expanded inframammary fold triangle: Improved results in large volume breast reductions.

CONTEXT: The inferior pedicle, Wise-pattern reduction mammaplasty is the most popular technique for breast reduction because of its reproducible results and reliability. However, complication rates in super obese patients or patients receiving large volume reductions are high, ranging from 35 to 78%. These complications include delayed healing, infection, seroma, nipple-areolar complex necrosis, fat necrosis and development of hypertrophic scars. AIMS: This study aimed to determine whether a modification to the standard Wise-pattern reduction technique, an expanded inframammary fold skin triangle, produces improved outcomes in high-risk large volume breast reduction patients. We report that this modification leads to improved outcomes by decreasing wound complications and improving aesthetic appearance. SETTINGS AND DESIGN: Twenty-two patients received the inferior pedicle Wise-pattern reduction mammaplasty, which was modified to include an 8 cm wide inferior pedicle. This pedicle was de-epithelialized and an 8 × 3 cm(2) triangle of skin was preserved at the inferior base to reduce tension at the triple point, inverted T-closure. MATERIALS AND METHODS: A retrospective review was performed on all patients who underwent reduction mammaplasty with the expanded inframammary fold (eIMF) technique as well as all patients who received the standard wise pattern technique. STATISTICAL ANALYSIS USED: A student t-test was performed for both reduction populations using SPSS software package. Statistical significance was defined as P < 0.05. RESULTS: The average patient age was 32.25 years old (range 18-59), average BMI was 35.0, and average tissue mass removed per breast was 1378.39 g. The modified technique was found to produce a statistically significant (P < 0.05) increase in the amount of breast tissue removed (693.96 g increase in the left and 571.21 g in the right) as well as a statistically significant (P < 0.05) reduction in dehiscence (75% reduction) and post-operative infection (44.10%). CONCLUSIONS: This method is an easily reproducible and reliable technique that produces a favourable cosmetic outcome with acceptable, sustainable results in high-risk reductions in obese patients.

Limb Salvage and Treatment of Posttraumatic Lymphedema in a Mangled Lower Extremity.

Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients' lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.

Imaging the Nerve "Allograft to Muscle Target" Technique in Neuroma Management.

Neuroma management has gained significant attention in the peripheral nerve literature in the past decade. Alongside techniques such as targeted muscle reinnervation and regenerative peripheral nerve interface, another technique known as the "allograft to nowhere" has emerged. This approach involves the placement of an extended allograft at the end of a nerve, creating a regrowth zone in cases where muscle or nerve targets are not available. Although technique and outcomes research has been performed regarding the above techniques, there is a lack of imaging studies to examine postoperative outcomes. The authors present a case of recurrent neuroma management using a combined nerve allograft to nowhere + muscle target, supported by postoperative imaging.

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.