Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention.

PURPOSE: Targeted muscle reinnervation (TMR) has emerged as a treatment for, and prevention of, symptomatic neuromas and has been reported to be of benefit in the hand. Anatomical studies establishing landmarks for consistent identification of the motor entry points (MEPs) to the intrinsic muscles have not been performed. The purpose of this study was to provide details regarding the MEPs to the intrinsic muscles, determine which MEPs are identifiable dorsally, and develop recommended sensory to MEP nerve coaptations for prophylactic TMR at the time of ray amputation or for management of symptomatic neuromas. METHODS: Motor entry points to the intrinsic hand muscles were dissected in 5 fresh latex-injected cadavers. Number of MEPs, diameter, surface of entry, and distance from dorsal (Lister tubercle) and volar (hamate hook) landmarks were recorded for each target muscle. The digital sensory nerve diameters were measured for size comparison. RESULTS: Motor entry points were identified to all 19 intrinsic muscles through a volar approach and 12 through a dorsal approach. For all fingers, at least 2 MEPs were consistently identified dorsally at the base of each amputation site innervating expendable muscles. Motor entry points to the thenar muscles were only reliably identified through a volar approach. Two recommended nerve coaptations for each digit amputation were identified. All had a favorable sensory-to-MEP diameter ratio less than 2:1. CONCLUSIONS: The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. CLINICAL RELEVANCE: These results can be applied clinically to assist surgeons in identifying the locations of MEPs to the intrinsic muscles when performing TMR in the hand for both neuroma treatment and prevention.

Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States?

Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57 300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.

Defining the Salvage Time Window for the Use of Ischemic Postconditioning in Skeletal Muscle Ischemia Reperfusion Injury.

BACKGROUND: The aim of this study was to determine the optimal salvage time window within which ischemic postconditioning can be used to ameliorate ischemia/reperfusion (I/R) injury in skeletal muscle. METHODS: A total of 48 Sprague-Dawley rats were divided into two groups: I/R only (control) and I/R with postconditioning. Subgroups were divided by duration of ischemia (2, 4, 6, and 8 hours). A pedicled gracilis muscle model was used. The postconditioning protocol consisted of six cycles of 15 seconds of reperfusion followed by 15 seconds of ischemia (total time = 3 minutes). Muscles were harvested 24 hours after I/R injury to examine tissue viability, histology, myeloperoxidase activity, and protective gene expression. RESULTS: Postconditioning groups showed improved muscle viability after 4 and 6 hours of ischemia time as compared with controls (p < 0.05). Higher expression of mitochondrial complexes I, II, III, endothelial nitric oxide synthase, inducible nitric oxide synthase, and Bcl-2 were observed in the postconditioning group after 4 and 6 hours of ischemia (p < 0.05). Lower expression of tumor necrosis factor-α and caspase 3 was observed in the postconditioning group at 4 hours (p < 0.05). Myeloperoxidase activity was similar in both groups at all-time points except 8 hours ischemia, where the control group had higher activity (p < 0.05). CONCLUSION: Results of this study demonstrate that the effective time window within which postconditioning is most effective for the salvage of skeletal muscle is between 4 and 6 hours of ischemia. Postconditioning offered improved mitochondrial and vascular function with decreased inflammation and cell death. This may be clinically useful as a postinjury salvage technique to attenuate I/R injury after 4 to 6 hours of ischemia.

Adipose-derived stem cell to epithelial stem cell transdifferentiation: a mechanism to potentially improve understanding of fat grafting's impact on skin rejuvenation.

BACKGROUND: Recent evidence suggests that lipofilling improves overlying skin composition and appearance. Adipose-derived stem cells (ADSC) have been implicated. OBJECTIVE: The authors identify ADSC transdifferentiation into epithelial stem cells through coexpression of GFP+ (green fluorescent protein positive) ADSC with the epithelial stem cell marker p63 in an in vivo fat grafting model. METHODS: Six male, GFP+ mice served as adipose tissue donors. Twelve nude mice served as recipients. Recipients were subdivided into 2 arms (6 mice/each arm) and received either whole-fat specimen (group 1) or isolated and purified ADSC + peptide hydrogel carrier (group 2) engrafted into a 1-cm(2) left parascapular subdermal plane. The right parascapular subdermal plane served as control. Skin flaps were harvested at 8 weeks and subjected to (1) confocal fluorescent microscopy and (2) reverse transcriptase polymerase chain reaction (RT-PCR) for p63 mRNA expression levels. RESULTS: Gross examination of skin flaps demonstrated subjectively increased dermal vessel presence surrounding whole-fat and ADSC specimens. The GFP+ cells were seen within overlying dermal architecture after engraftment and were found to coexpress p63. Significantly increased levels of p63 expression were found in the ADSC + hydrogel skin flaps. CONCLUSIONS: We offer suggestive evidence that GFP+ ADSC are found within the dermis 8 weeks after engraftment and coexpress the epithelial stem cell marker p63, indicating that ADSC may transdifferentiate into epithelial stem cells after fat grafting. These findings complement current understanding of how fat grafts may rejuvenate overlying skin.

Strategies to Improve Resident Wellness in Plastic Surgery Training.

Residency is known to be a challenging time in a surgeon's career. Surgical residents must learn the breadth of their field and develop technical skills while maintaining relationships and well-being outside their training. High burnout rates are well documented among all medical specialties, particularly during residency. Proven strategies in medical education that help decrease burnout and improve resident well-being, while maintaining quality patient care, have been reported in the medical education literature. However, little has been published specific to plastic surgery training programs. We discuss strategies that can be implemented into the curricula and workflow at plastic surgery residency programs to maximize resident well-being. We advocate for a multifaceted approach that includes a night float system, day call, integrating advanced practice providers to offload noneducational resident tasks, and establishing a wellness program. It is our hope that these strategies may serve as a guide for plastic surgery residency programs to promote general wellness and prevent burnout among trainees.

Strategies to Reduce Congestion in the Resident Match: What Can Plastic Surgery Learn from Other Specialties?

Many medical specialties are experiencing congestion in the residency match process because of increasing competition amongst applicants to secure a training position. With rising application numbers for a stable number of positions, the result is an inefficient use of time and financial resources on behalf of both the residency applicants and programs. Solutions to address congestion in the match process have been proposed in the literature, and other specialties have implemented specialty-wide reforms. Methods: The Pubmed and Web of Science databases were queried using keywords related to the residency match and resident selection. The initial search yielded 372 results. Titles and abstracts were evaluated for inclusion and 93 articles met criteria for full-text evaluation. The bibliographies of these publications were reviewed for additional references. Results: Numerous strategies to reduce congestion in the match were identified across specialties. Implemented reforms include a centralized preference signaling system, an interview cap, a staged or consortia match, and publication of transparent program-specific resident selection criteria. We discuss pros and cons of different strategies to reduce congestion in the match and summarize the effects that recent reforms have had on other specialties. Conclusions: Plastic surgery as a field is at a distinct advantage to be a leader in transforming the residency match process, as we are a small and historically innovative group. We hope to spark discussion amongst students, residents, and program faculty with the goal of creating a more efficient match process.

A 15-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Carpometacarpal Joint Arthroplasty.

BACKGROUND: The purpose of this study was to help understand national practice patterns in carpometacarpal (CMC) arthroplasty and how they have evolved with evidence-based recommendations over the past 15 years. METHODS: The American Board of Plastic Surgery (ABPS) started collecting practice data on primary CMC joint arthroplasty in 2006 as a portion of its continuous certification (CC) process. Data on primary CMC arthroplasty from May 2006 through December 2013 were reviewed and compared to those from January 2014 to March 2020. National practice trends observed in these data were evaluated. Comprehensive evidence-based medicine reviews published in 2008, 2011, 2013, and 2017 were reviewed alongside the CC data. RESULTS: In all, 570 primary CMC joint arthroplasty cases were included from May 2006 to March 2020. The average age at the time of repair was 62 years and the patient population was predominantly female (79%). Most cases were done under general anesthesia (69%), and there was an increase in the use of regional anesthesia with nerve block when our 2 cohorts were compared (27% vs 37%; P = .020). A trapezium excision with flexor carpi radialis tendon ligament reconstruction was the most popular technique (72%) and an increase in the use of simple trapeziectomy was observed (6% vs 14%; P = .001). One-third of patients did not receive any form of deep vein thrombosis prophylaxis. CONCLUSIONS: The ABPS CC data provide a databank that allows for direct observation of national practice trends and sheds light on potential avenues for improvement in patient care.

Autologous Breast Reconstruction is Associated with Lower 90-day Readmission Rates.

BACKGROUND: Breast reconstruction is associated with improved quality of life after mastectomy. Options for breast reconstruction include autologous and implant-based methods. Although autologous reconstruction is more technically challenging and requires longer operative time, it is thought of as the gold standard. Our study examined differences in 90-day readmission rates between implant-based and autologous breast reconstruction using discharge data from the National Readmission Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. METHODS: The National Readmission Database was used to identify patients undergoing postmastectomy breast reconstruction. Patients were selected using ICD-10 PCS codes linked to autologous and implant-based reconstruction. Ninety-day readmission rates were determined. After matching the two groups on a 1:1 basis for baseline comorbidities and demographics, a multivariable logistic regression analysis was performed to variables associated with higher readmission rates. RESULTS: The leading diagnoses associated with readmissions were infectious and pulmonary. After one to one matching, autologous breast reconstruction, private insurance versus Medicaid, and income quartile 4 versus 1 were all less likely to be readmitted within 90 days of discharge. Patients with a high Charlson index and those with a longer length of initial hospital stay are significantly more likely to be readmitted within 90 days. CONCLUSIONS: Patients undergoing autologous breast reconstruction were 23% less likely to be readmitted within 90 days from discharge. Fewer comorbidities, shorter length of hospital stay, and higher socioeconomic status are also associated with lower readmission rates following breast reconstruction.

Targeted muscle reinnervation of a muscle-free flap for improved prosthetic control in a shoulder amputee: case report.

We report a case of targeted muscle reinnervation of a muscle free flap for improved prosthetic control in a patient who had an amputation of the left upper extremity at the level of the shoulder after a severe electrical burn. The reinnervated muscle free flap receives signals from the brachial plexus, and these signals are amplified to provide an interface for a myoelectric prosthesis. This allows for more coordinated and efficient control of the artificial limb.

Stimulating angiogenesis by hyperbaric oxygen in an isolated tissue construct.

BACKGROUND: Hyperbaric oxygen (HBO2) treatment has been shown to stimulate angiogenesis in prefabricated myocutaneous flaps. We conducted the current study to determine optimal HBO2 treatment intervals for peak angiogenesis. METHODS: Lewis rats were implanted subcutaneously with silicone molds in the inguinal region. Molds contained inguinal fat, a vascular pedicle and Matrigel plug. Thirty-two animals were randomized into four groups: HBO2 Treatment (2.5 atm of 100% oxygen, 90 minutes, 2x/day)--Group 1 (seven days) or--Group 2 (14 days); and Control Treatment (room air at atmospheric pressure)--Group 1 (seven days) or--Group 2(14 days). Implants were harvested, processed for H&E staining, and imaged digitally; angiogenesis was assessed by grade of vascularization at the Matrigel/fat boundary. Intergroup grading differences were assessed statistically. RESULTS: Vascularization in seven-day HBO2-treated implants was significantly increased compared to seven-day controls (p = 0.008). Vascularization in 14-day HBO2-treated implants was significantly decreased compared to 14-day controls (p = 0.012). There was no significant difference between seven-day HBO-treated implants and 14-day controls (p > 0.05). CONCLUSIONS: Short-term HBO2 exposure appears to increase angiogenesis in isolated tissue constructs. Prolonged HBO2 exposure may lead to vascular pruning. Short-term HBO2 exposure appears to expedite the natural vascularization process, resulting in equivalent vascularization in a shorter time.

Mucosal Melanoma.

Mucosal melanoma is a rare but aggressive cancer arising in mucosal surfaces most commonly in the head and neck. The clinical presentation is often nonspecific and differs in relation to the site of origin so often diagnosis is delayed resulting in poor prognosis. Mucosal melanoma has a 5-year survival of only 25%. Surgery with negative margins is the mainstay of treatment but dependent on several variables including anatomic location, involved structures, and size of tumor. Although not well defined given the rarity of mucosal melanoma, there is a role for radiation and systemic therapy in the treatment of this disease.

Phalangeal and Metacarpal Fractures of the Hand: Preventing Stiffness.

Fractures of the phalangeal or metacarpal bones of the hand are common. Many of these fractures are treated without surgery. However, both conservative and operative management of fractures of the hand can result in stiffness. Stiffness is the most common complication in the management of hand fractures. The key to preventing stiffness is early range of motion exercises. This article challenges many of the current treatment regimens offered to patients with the so-called unstable fractures. The evaluation of the patients' function is the primary factor that should determine the course of conservation versus operative management. X-rays do not demonstrate function and therefore act as an adjunct only to the care of the patient. The goal of treating hand fractures is to restore function. Early motion may not only improve healing but may also hasten the return to normal hand function. The tenets of how to prevent stiffness are described in this review.

Extirpative Considerations of Melanoma of the Head and Neck.

The incidence of melanoma is continuing to rise in the United States, and head and neck melanomas account for 25% of all cutaneous melanomas. The National Comprehensive Cancer Network guideline recommendations for surgical margins and sentinel lymph node biopsy in head and neck melanomas are the same as cutaneous melanoma located in other regions, but require special considerations when performing wide local excision, sentinel lymph node biopsy, and completion lymph node dissection and reconstruction taking into account the location of the melanoma and structures involved in and around the suggested margins.

Spitz Nevus: Review and Update.

The Spitz nevus is an uncommon melanocytic nevus. These lesions classically appear in childhood as a red, dome-shaped papule. They appear rarely in adults and may be pigmented. The Spitz nevus can develop suddenly and grow rapidly, reaching a 1-cm diameter in 6 months or less. There are 3 classes of spitzoid neoplasms: typical Spitz nevus, atypical Spitz nevus, and spitzoid melanoma. The diagnosis should be cautiously differentiated, especially in children. Immunohistochemistry and molecular studies have been helpful in differentiating difficult cases; however, no set of criteria has been accepted to predict biological behavior of atypical Spitz nevi.

Grafting and Other Reconstructive Options for Nail Deformities: Indications, Techniques, and Outcomes.

This article reviews the nomenclature, anatomic components, and physiologic growth involving the perionychium. Fingertip and nailbed injuries are commonly encountered problems in hand surgery. This article focuses primarily on dealing with chronic nailbed deformities following traumatic injury such as nonadherence, split nails, avulsion loss, and hook nails. Nail deformities secondary to pincer nail, mass effect, and pigmented lesions are reviewed as well. The underlying pathology and treatment options are examined for each deformity. The senior author highlights technical pearls and surgical planning for his preferred methods of reconstruction.

Lentigo Maligna.

Lentigo maligna (LM) is a melanocytic neoplasm found on chronically sun-exposed areas of the body, particularly the head and neck. It commonly occurs in the elderly and has been referred to as a "senile freckle." It has also been termed "Hutchinson melanotic freckle," as it was first described by John Hutchinson in 1892. LM is defined as melanoma in situ and thus confined to the epidermis. LM lesions that invade the dermis are termed lentigo maligna melanoma, 1 of the 4 subtypes of malignant melanoma.

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow.

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Radiation Therapy for Local Cutaneous Melanoma.

While primary treatment for melanoma consists of surgical resection and chemotherapeutics, radiation can be used as either definitive or adjuvant therapy in certain clinical scenarios. This chapter aims to explore the indications for primary definitive radiotherapy as well as adjuvant treatment following resection. Delivery, dose, fractionation, and toxicity of radiation treatment will be discussed. As our understanding of melanoma tumor biology increases, the role of radiotherapy may expand for more effective treatment of oligometastatic disease.

Adjuvant and Neoadjuvant Therapeutics for the Treatment of Cutaneous Melanoma.

Adjuvant therapy plays an integral role in the treatment algorithm for stage III and stage IV cutaneous melanoma. Current ongoing clinical trials are exploring the effects of neoadjuvant therapeutics, specifically for the presurgical treatment of high-risk, borderline resectable disease. In both the adjuvant and neoadjuvant settings, the early chemotherapeutic and biochemical antitumor agents are making way to newer immune therapies, mutation-specific targeted therapies, and oncolytic vaccines that are transforming the treatment of malignant melanoma. The use of these systemic therapies in addition to surgical resection has been shown to increase both overall and progression-free survival.

Melanoma of the Hands and Feet (With Reconstruction).

Melanomas only account for 4% of all dermatologic cancers yet are responsible for 80% of deaths. Notably, melanomas of the hand and foot have a worse prognosis when compared with melanomas of other anatomic regions. Likely this is due to intrinsic biologic characteristics, delayed diagnosis, difficult surgical excision due to delicate anatomy, and lack of definitive diagnostic and therapeutic guidelines. The most common locations of melanoma of the hand, in order of decreasing frequency, are subungual area, dorsal surface, and palmar surface. The most common locations of melanoma of the foot are the plantar surface, dorsal surface, and subungual area, in decreasing frequency. Diagnosis of melanoma of the hand and foot can be difficult because the traditional "ABCDE" (asymmetric shape, border, color, diameter, evolution) rules do not apply. Newer acronyms have been proposed in literature including "CUBED" (colored, uncertain, bleeding, enlarged, delayed) and "ABC rule for Subungual Melanoma." Once diagnosed, treatment is primarily surgical excision and reconstruction. The goal for the surgeon is to maintain the function and anatomy of the hand or foot.