Relative motion flexion following zone I-III flexor tendon repair: Concepts, evidence and practice.

STUDY DESIGN: Narrative review and case series. INTRODUCTION: The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis. METHODS: We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data. RESULTS: We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients. DISCUSSION: We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use. CONCLUSIONS: There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series.

STUDY DESIGN: A retrospective, single-center, consecutive case series. INTRODUCTION: In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. PURPOSE OF THE STUDY: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. METHODS: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. RESULTS: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. CONCLUSION: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

"Toward Breast Reinnervation- What is our Endpoint" A systematic review of normal breast sensibility.

BACKGROUND: To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement. METHODS: We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated. RESULTS: A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility. CONCLUSIONS: The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.

Novel Use of an Internal Distractor for Metacarpal Lengthening.

BACKGROUND: In patients who have had proximal digit amputation, metacarpal distraction osteogenesis is an option to improve digital length and function. One drawback is that traditional external distraction devices are large and cumbersome; the option of a low-profile internal device is therefore appealing. Internal distractors are commonly used in craniofacial reconstruction, but use in the hand has not been reported. We describe a case series of the novel use of an internal distractor in metacarpal lengthening. METHODS: In this single-center case series, patients who underwent metacarpal distraction by the senior author using a uniplanar internal distractor were reviewed, and indications, outcomes, and complications were analyzed. RESULTS: There were 5 cases in 4 patients (age range: 7-33 years). Indications were traumatic amputation in 4 cases and congenital hypoplasia in 1. All were successfully distracted, with a mean final length gain of 1.3 cm (range: 1.0-1.7 mm). Mean time from device placement to consolidation was 3.5 months. Complications included activation arm site infection in 2 cases, both occurring after the distraction period, necessitating device removal before full consolidation. In these cases, the device was removed after the distraction period and replaced with a Kirschner wire for stabilization through the consolidation period. CONCLUSIONS: Metacarpal distraction was successfully achieved with an internal distraction device. Although infection was common, it occurred after the distraction period and did not preclude length gain. We feel that this low-profile device offers advantages over cumbersome external devices typically used for metacarpal lengthening.

The reliability and advantages of the sentinel vein as a microsurgical recipient vessel.

Free flaps to the scalp, calvaria, and anterior and middle cranial fossae are typically transferred to the superficial temporal artery and vein. Occasionally the superficial temporal vein is unsuitable for microvascular anastomosis. In such cases, we have had success using the sentinel vein, a perforating vein located in the anterior aspect of the deep temporal fat pad. This article describes the pertinent anatomy, our clinical experience, and the advantages of the sentinel vein as a microsurgical recipient vessel.

Isolated Spinal Accessory Nerve Palsy from Volleyball Injury.

Spinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy.

Inclusion of tissue beyond a midline scar in the deep inferior epigastric perforator flap.

BACKGROUND: A lower abdominal midline scar is known to restrict the amount of tissue that can be included in a deep inferior epigastric perforator (DIEP) flap. However, reconstructive demands have occasionally led us to include substantial territory beyond the scar. The purpose of this study is to review our experience with such flaps and to determine whether a meaningful amount of tissue can be reliably harvested across a midline scar. METHODS: Within a series of 125 DIEP flaps harvested across the entire lower abdomen (zones I-IV), 11 contained a midline scar. These 11 cases were compared with the remaining 114 in terms of (1) the amount of tissue beyond the scar that could be retained with the flap based on intraoperative assessment of vascularity and (2) postoperative complications. RESULTS: A significantly smaller percentage of the flap volume could be retained in scarred abdomens (70% of the harvested ellipse [ie, 20% beyond the midline]) versus unscarred abdomens (83%; P = 0.01). Complications were more frequent in the flaps with scars (55% vs. 25%; P = 0.04), although most of these complications were easily manageable and acceptable outcomes were achieved in all 11 cases. CONCLUSION: The rate of complications is significantly higher when tissue across a midline scar is included in a DIEP flap. However, in our experience, these complications are relatively mild, and in most cases, a substantial amount of tissue beyond the midline can be used, thereby increasing the volume available for reconstruction without resorting to dual-supply procedures.

Remote real-time monitoring of free flaps via smartphone photography and 3G wireless Internet: a prospective study evidencing diagnostic accuracy.

This prospective study was designed to compare the accuracy rate between remote smartphone photographic assessments and in-person examinations for free flap monitoring. One hundred and three consecutive free flaps were monitored with in-person examinations and assessed remotely by three surgeons (Team A) via photographs transmitted over smartphone. Four other surgeons used the traditional in-person examinations as Team B. The response time to re-exploration was defined as the interval between when a flap was evaluated as compromised by the nurse/house officer and when the decision was made for re-exploration. The accuracy rate was 98.7% and 94.2% for in-person and smartphone photographic assessments, respectively. The response time of 8 ± 3 min in Team A was statistically shorter than the 180 ± 104 min in Team B (P = 0.01 by the Mann-Whitney test). The remote smartphone photography assessment has a comparable accuracy rate and shorter response time compared with in-person examination for free flap monitoring.

External doppler monitoring of free flaps through negative pressure dressings.

The negative pressure dressing is a highly effective modality for coverage and bolstering of skin grafts in the early postoperative period. In the situation of a skin graft over a free flap, the surgeon might be inclined to avoid this modality out of concern that the dressing would deleteriously effect flap survival or impede flap monitoring. This case series supports the safety of the negative pressure dressing and demonstrates a technical modification that permits external Doppler monitoring of the flap through the dressing. Thus, this technique provides an ideal environment for skin graft healing while maintaining the ability to monitor the flap in a straightforward manner and also simplifies nursing care.

Morgellons Disease: The Spread of a Mass Psychogenic Illness via the Internet and Its Implications in Hand Surgery.

Somatic manifestations of mental illness sometimes occur in patients presenting to hand specialists. These conversion disorders can also occur in groups, a phenomenon known as "mass psychogenic illness." The increasing penetrance of the Internet and social media in modern society has greatly facilitated the interaction of patients with others with similar disorders. One example relevant to hand surgery is "Morgellons disease," a disorder popularized in 2002 and characterized by a firm belief in foreign material extruding from the skin, leading to nonhealing, self-inflicted ulcerations and excoriations. A series of 4 patients collected through an informal survey of hand surgeons regarding experience with Morgellons disease is reviewed and discussed. All patients in the series presented with a chief complaint of foreign material extruding from the hand. In 1 case, the complaint was made by a young patient's mother. In none of the patients were foreign bodies identified, although 2 patients demonstrated significant ulcerations and scars from self-excoriation. Three patients had a somatic condition affecting the hand or upper extremity, 1 directly related to self-excoriation and 2 unrelated. Treatments, workups, and ultimate outcomes varied among patients. Patients presenting with Morgellons disease often undergo multiple unnecessary tests and are at risk of inappropriate procedures. It is therefore important that providers have a compassionate understanding of the involved psychology. Herein, we offer an approach to the recognition of and treatment strategies for these patients.

Extending the Reach of Craniofacial Free Flaps Using the Descending Branch of the Lateral Circumflex Femoral Vessels.

SUMMARY: Craniofacial free tissue transfer is sometimes complicated by insufficient pedicle length and/or paucity of recipient vessels. A saphenous vein graft can be used to reach the high-flow, large-caliber vessels of the neck, but because of the vein's taper and thick wall, there is often a mismatch. Following the principle of like-for-like, the authors prefer the descending branch of the lateral circumflex femoral vessels to achieve a more anatomical pedicle extension for free tissue transfer in complex craniofacial reconstruction. The authors' experience using the descending branch of the lateral circumflex femoral pedicle extender from 2010 to 2019 was reviewed. Indications, patient characteristics, reconstruction site, flap type, pedicle length, recipient vessels, and vascular complications were noted. The authors reviewed two strategies for implementation of the pedicle extender: in some cases, the flap was first transferred and allowed to perfuse on the descending branch of the lateral circumflex femoral vessels in the thigh, and then transferred to the recipient vessels (double-ischemia transfer); and in other cases, the flap and pedicle extender were transferred such that the flap underwent a single period of ischemia (single-ischemia transfer). The descending branch of the lateral circumflex femoral pedicle extender was used in 17 craniofacial cases. Indications included tumor, trauma, osteoradionecrosis, and congenital. Double-ischemia transfer was used in eight cases and single-ischemia transfer in nine. The longest pedicle extender in the series was 15 cm. Arterial thrombosis occurred in one case. This case series demonstrates that the descending branch of the lateral circumflex femoral pedicle extender is a viable option for complex craniofacial free tissue transfer cases. It provides ample length and excellent vessel match, following the like-for-like principle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The shunt-restricted arterialized venous flap for hand/digit reconstruction: enhanced perfusion, decreased congestion, and improved reliability.

BACKGROUND: Arterialized venous flaps can be useful for hand/digit reconstruction, providing very thin skin coverage. However, their popularity has been limited by concerns over poor peripheral perfusion and severe congestion, which may be to be due to unrestricted arteriovenous shunting and pressurization of the efferent vein. To mitigate these problems, we design our flaps to restrict shunting. This report describes our clinical experience with these techniques. METHODS: A consecutive series of 15 flaps was reviewed. All flaps were transferred with antegrade flow. Shunt restriction was achieved in one of the following ways, according to the flap's venous pattern: (1) two parallel veins (II-pattern): use of separate veins for inflow and outflow; (2) two parallel veins with connecting branch (H-pattern): as for II-pattern, with ligation of connecting branch; (3) branching vein (Y/lambda-pattern): ligation of one branch near bifurcation, with use of that branch for outflow and other segment for inflow (or vice versa); and (4) one continuous vein (I-pattern): ligation at midpoint. Laser Doppler flowmetry was used to compare flap perfusion with and without shunt restriction in two patients. RESULTS: All flaps survived entirely. Color, turgor, temperature, and capillary refill mimicked conventional arterial flaps, facilitating postoperative monitoring. Six flaps demonstrated mild-to-moderate venous congestion at the afferent end, with some developing epidermolysis but no full-thickness loss. Intraoperative flowmetry showed enhanced perfusion in the flap's periphery when shunting was restricted. CONCLUSIONS: Restriction of arteriovenous shunting enhances peripheral perfusion and decreases congestion of venous flaps, thereby improving reliability and utility for hand/digit reconstruction.

Bilateral breast revision augmentation with deep inferior epigastric perforators/superficial inferior epigastric artery flaps: case reports and literature review.

Free tissue transfer is rarely used for cosmetic breast enlargement, but in certain cases of failed augmentation with implants, it may be a justifiable alternative. Our experience in treating bilateral capsular contracture with deep inferior epigastric perforators/superficial inferior epigastric artery flaps has been very favorable. Advantages include avoidance of implants and their related problems, more natural feel and shape, and ancillary abdominoplasty. Although the operation is substantially lengthier and more complicated than implant replacement, and the overall treatment cost much higher, we feel that surgeons who are skilled in perforator-based free tissue transfer should consider such procedures in the appropriate circumstances.

Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap.

BACKGROUND: Elevation of the deep inferior epigastric perforator (DIEP) flap interrupts its superficial venous system, and if drainage through the deep venous system is inadequate the flap may develop congestion. The purpose of this retrospective study was to determine the fate of the congested DIEP flap and to optimize the strategy for its salvage. METHODS: Thirty-two of 162 patients who underwent unilateral breast reconstruction with a DIEP flap developed venous congestion. For the purpose of outcome analysis, cases were retrospectively allocated to "observation-only" (group A, n = 11), postoperative salvage (group B, n = 7), and intraoperative salvage (group C, n = 14), and complications among the various groups were compared to determine the necessity and optimal timing of salvage intervention. RESULTS: Two flaps (1 in group A, another in group B) failed completely, giving a success rate 98.8%. The complication rate and hospital stay were significantly lower in group C than in group B (P = 0.03, P = 0.02). The rate of venous congestion requiring salvage procedures was 13%, with a salvage rate of 95%. Salvage procedures included venous augmentation with an additional recipient vein in 7 procedures, adding superficial inferior epigastric vein (SIEV) to DIEV in 11 procedures, and substituting with SIEV in 7 procedures. There was no statistical difference in flap salvage rate using the SIEV between "augmentation" and "substitution." CONCLUSIONS: The salvage procedures for venous compromised DIEP flap are better performed intraoperatively rather than postoperatively to prevent further complications. The engorged SIEV could be incorporated by anastomosing to an additional recipient vein or adding to the DIEV-internal mammary vein axis or substituting for DIEV.

Vascularized bone transfer for severe injury around the ankle.

Severe injuries around the ankle are very difficult to treat. Although technically demanding, vascularized bone transfer has the potential to span bone defects, eradicate infection, and provide soft tissue coverage all in one stage. The fibula is the best choice for transfer as it produces the best results and the least donor site morbidity. Complications are reasonably common as in all complex reconstructive surgery, but in the properly selected patient this approach offers the best chance for salvage of a functional limb. The purpose of this review is to evaluate some of the various options available for managing severe injuries around the ankle with particular focus on vascularized bone grafts, particularly the vascularized fibular bone graft. Selection criteria, surgical timing, potential donor sites, as well as outcomes and possible complications are presented regarding the available options for vascularized bone grafts in managing severe ankle injuries.

The Subtleties of Success in Simultaneous Augmentation-Mastopexy.

BACKGROUND: Many have challenged the safety of performing breast augmentation and mastopexy simultaneously. However, staging these procedures incurs the increased risk and inconvenience of two periods of anesthesia and recuperation. The authors set out to evaluate the occurrence of complications across the populations of patients undergoing (1) combined augmentation-mastopexy, (2) isolated augmentation, and (3) isolated mastopexy. METHODS: A retrospective analysis of one surgeon's consecutive series of each of these procedures from 2000 to 2009 was conducted. Preoperative risk factors were characterized. Sixteen different complications were examined, and those necessitating operative revision were tracked. Statistical analysis was performed looking for significant differences between the surgical groups. RESULTS: No instances of infection, tissue loss, or implant exposure occurred among the 297 patients over an average follow-up period of 15.5 months. The isolated mastopexy group did not provide sufficient data for statistical comparison. Tissue-related complications were most common in the combined procedure group. The operative revision rate for isolated augmentation was 7.97 percent compared with a combined procedure revision rate of 12.4 percent (p = 0.28). CONCLUSIONS: The majority of complications in this series comparing simultaneous augmentation-mastopexy to isolated augmentation were minor. Complications requiring operative revision were not found to be significantly different between the two groups. There was a much lower reoperation rate (12.4 percent) with the combined procedure compared with a 100 percent reoperation rate when the procedure is staged. Thus, the authors feel the combined procedure can safely be part of every plastic surgeon's practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.