Microvascular lining options for subtotal and total nasal reconstruction: A scoping review.

BACKGROUND: Restoration of nasal lining is essential in reconstruction of subtotal/total nasal defects. When local flaps are inadequate, a microvascular flap should be used. The purpose of this scoping review is to map the literature and identify the described flap options for subtotal/total nasal reconstruction. Further to that, we will summarize the stated advantages and disadvantages, evaluate functional and esthetic outcomes, and appraise the current body of literature. METHODS: An electronic literature search was completed. Studies required adult patients with subtotal/total nasal defects and lining reconstruction with microvascular free flap. Two independent reviewers completed screening and data extraction. Flap characteristics, advantages, disadvantages, functional and esthetic outcomes were reviewed. Two independent reviewers evaluated study quality. RESULTS: Of 305 initial articles, 22 studies were included (13 case reports, 9 case series) accounting for 65 flaps. Microvascular flaps varied by composition and anatomical location. For functional outcome, 13 studies used clinical exam by surgeon, 5 reported patient being satisfied, 3 studies used endoscopy, and 1 study used nasometry. Assessing esthetic outcome, 13 studies used clinical exam by surgeon, 5 studies reported patient being satisfied, 1 study used patient-reported outcome measures, and 16 studies included photos. Study quality (modified CARE and PROCESS checklists) was deemed poor. Quality of available evidence was level IV. CONCLUSIONS: Microvascular free flaps for nasal reconstruction, confer an overall satisfactory functional and esthetic outcome. All studies lack a systematic and comprehensive approach to assessing and reporting these outcomes. Future research should provide objective assessment and utilize patient reported outcome measures.

Single Digit Index Finger Amputation-To Replant or Not?

Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.

Contexte: La réimplantation isolée de l'index est souvent considérée comme une contre-indication compte tenu de la gêne causée au fonctionnement de la main une fois réimplanté. Des études récentes démontrent des résultats fonctionnels, subjectifs et globaux, comparables pour les réimplantations digitales du fléchisseur de l'index en zone II comparativement aux amputations de révision. Nous avons donc cherché à identifier l'avis actuel des stagiaires et du personnel de chirurgie plastique traitant des amputations isolées en zone II, incluant les caractéristiques de la blessure et l'influence des patients. Méthodes: Une enquête comportant dix-sept questions a été envoyée à trois reprises avec l'approbation de la Société canadienne de chirurgie plastique aux adresses de courriel de tous les membres listés. La participation était volontaire et les réponses à l'enquête ont été compilées et analysées au moyen du logiciel statistique SPSS. Résultats: Le taux de réponse à l'enquête a été de 38,5 %. À la question de savoir si le chirurgien réimplanterait un index isolé, fléchisseur zone II, après amputation nette, 55,3 % des répondants ont choisi « oui ¼ et 44,7 % ont répondu « non ¼. Le personnel (51,5 %) était moins susceptible de réimplanter un index après amputation isolée. La probabilité de réimplantation diminuait nettement en cas de lésion par écrasement (12,4 %) et arrachement (17,1 %). Le tabagisme était la caractéristique du patient le plus susceptible de modifier la décision d'un chirurgien (61,9 %). Une mauvaise amplitude de mouvement (77,5 %) et satisfaction du patient (72,5 %) ont été les raisons citées le plus souvent pour ne pas réimplanter. Conclusion: Il existe, parmi les chirurgiens plasticiens canadiens, un désaccord sur la manière dont les amputations isolées d'un index (fléchisseur zone II) doivent être gérées. La revue des publications montre que ces notions et l'enseignement antérieur concernant les réimplantations soulignent les multiples biais inhérents aux chirurgiens pour ce qui concerne l'intérêt et la valeur de la réimplantation d'un seul doigt.

Systematic Review Comparing Cost Analyses of Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Treatment of Dupuytren's Contracture: Une analyse de coûts systématique comparant la fasciectomie, l'aponévrotomie percutanée à l'aiguille et l'injection de collagénase pou traiter la maladie de Dupuytren.

PURPOSE: Surgeons now have a variety of treatment options for Dupuytren's contracture including traditional partial fasciectomy (PF), percutaneous needle aponeurotomy (PNA), and collagenase Clostridium histolyticum (CCH) injection. An important factor in clinical decision making is the cost-effectiveness of the various modalities, as will be discussed in this article. METHODS: A literature search was performed by 2 independent reviewers. A total of 14 articles and 3 abstracts met inclusion criteria. Papers were excluded for non-English language, insufficient breakdown of costs by treatment type, promotional materials, or works-in-progress. Cost data were extracted and subsequently converted to US dollars. Weighted means were used to objectively pool data that were sufficiently similar in methodology and population. RESULTS: Seven observational cohort studies were pooled and found to have a weighted mean cost in favour of PNA at US$3335 per patient as compared to CCH at US$3673.14 and PF at US$4734.14. Two expected-value decision analysis models were in agreement that PF is not cost-effective, but they differed on whether PNA or CCH was the most cost-effective strategy. Two cost minimization studies agreed that CCH was less costly than PF by US$486. One cost-benefit analysis found no significant cost benefit to CCH or PF, but found significant indirect benefit to CCH. Overall 10 of 17 studies found CCH to be superior with respect to direct cost, indirect cost, or both. Only 2 of the 17 studies found PF to be the most cost-effective method. Of the 7 studies that considered PNA, 4 found it to be lowest cost. CONCLUSION: The vast majority of studies found PF to be the most costly treatment modality; however, it is still the treatment of choice in certain clinical scenarios. It is difficult to compare CCH to PNA, as many studies did not consider PNA. More studies, especially considering indirect costs, are required to be able to accurately determine which method is most cost-effective.

OBJECTIF: Les chirurgiens possèdent désormais diverses options pour traiter la maladie de Dupuytren, y compris la fasciectomie partielle (FP) classique, l'aponévrotomie percutanée à l'aiguille (APA) et l'injection de collagénase issue du Clostridium histolyticum (CCH). Le rapport coût-efficacité des diverses modalités est un facteur important de la prise de décision clinique, comme on le verra dans le présent article. MÉTHODOLOGIE: Deux analystes indépendants ont procédé à une analyse bibliographique. Au total, 14 articles et trois résumés respectaient les critères d'inclusion. Les articles qui n'étaient pas rédigés en anglais, dont la ventilation des coûts par type de traitement était insuffisante, qui contenaient du matériel promotionnel ou qui rendaient compte de travaux en cours étaient exclus. Les chercheurs ont extrait les données sur les coûts et les ont converties en dollars américains. Ils ont utilisé les moyennes pondérées pour regrouper objectivement les données dont la méthodologie et la population étaient suffisamment semblables. RÉSULTATS: Les chercheurs ont regroupé quatre études de cohorte observationnelles et ont constaté que le coût moyen pondéré de l'APA, à 3 335 $ par patient, était plus favorable que celui de la CCH, à 3 673,14 $ et de la FP, à 4 734,14 $. Trois modèles d'analyse décisionnelle de la valeur attendue concluaient que la FP n'était pas rentable, mais divergeaient sur le coût de l'APA et de la CCH. Deux études de minimisation des coûts ont convenu que la CCH coûtait 486 $ de moins que la FP. Une analyse coût-bénéfice n'a pas établi de coûts-avantages significatifs pour la CCH ou la FP, mais a constaté des avantages indirects significatifs pour la CCH. Bref, selon 11 des 17 études, la CCH était supérieure sur le plan des coûts directs, des coûts indirects ou de ces deux coûts. Seulement deux des 17 études ont indiqué que la FP était la plus rentable. Sur les sept études qui évaluaient l'APA, quatre ont indiqué qu'il s'agissait de la moins coûteuse. CONCLUSION: La grande majorité des études ont établi que la FP était le traitement le plus coûteux, mais elle demeure à privilégier dans certains scénarios cliniques. Il est difficile de comparer la CCH à l'APA, car de nombreuses études n'évaluaient pas l'APA. Il faudra mener plus d'études, notamment sur les coûts indirects, pour déterminer la méthode qui est vraiment la plus rentable.

Surgical Management of Abdominal Anterior Cutaneous Nerve Entrapment Syndrome: Case Report, Surgical Technique, and Literature Review.

Abdominal anterior cutaneous nerve entrapment syndrome (ACNES) is an emerging diagnosis, with estimated incidence of 13%-30% of the adult population. It is a syndrome characterized by chronic abdominal pain caused by entrapment of cutaneous branches of thoracoabdominal nerves at the lateral border of the rectus abdominis muscle. If conservative treatment with pain medication, botulinum toxin, or lidocaine injections is inadequate, surgical management is indicated. METHODS: We present a case of a 40-year-old woman presenting with a 1-year history of daily right anterior abdominal wall pain, consistent with a diagnosis of ACNES. We describe our approach for an anterior neurectomy of the intercostal nerve with closure of its fascial foramen. RESULTS: Three months after surgery, she remained pain free and was back to work full time. At a 13-month follow-up, the patient reported that her pain had resolved completely following surgery. CONCLUSIONS: Results are encouraging following anterior neurectomy for ACNES. Surgical descriptions in the literature are brief, with limited pictorial account. Our detailed surgical approach is provided along with a review of the existing literature on the management of ACNES.

Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review.

BACKGROUND: Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation. METHODS: A literature search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed according to PRISMA guidelines. All studies reporting on functional outcomes, return to work, or secondary surgeries following replant of traumatic proximal to carpus amputation were included. RESULTS: Of the 753 articles, 13 studies were included, accounting for 136 major upper extremity replants (0 shoulder, 36 arm, 14 elbow, 86 forearm). Average age was 35 (24 -47) years, with average follow-up of 8 years (2 -18). Chen's Functional Criteria was the most common tool for reporting outcomes (10/13). Level of injury was related to functional outcome, with excellent to good Chen scores for replants distal to elbow, and poor Chen scores for replants at or proximal to elbow. Return to work correlated with level of replantation, with successful return for 65% of forearm, 43% of elbow, and 32% of arm replants. A mean of 2.4 secondary procedures were required. CONCLUSIONS: This study provides insight into major upper extremity replantation, to assist in patient counseling and surgical decision making. Good functional outcomes and successful return to work are directly related to level of injury following major upper extremity replant. Patients should be counseled that more than 1 secondary procedure may be required.

Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰.

PURPOSE: Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone.2,3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS: A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS: Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS: The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

Efficient Imaging: Examining the Value of Ultrasound in the Diagnosis of Traumatic Adult Brachial Plexus Injuries, A Systematic Review.

BACKGROUND: Traumatic brachial plexus injury (BPI) can result in debilitating sequelae of the upper extremity. Presently, therapeutic decisions are based on the mechanism of injury, serial physical examination, electromyography, nerve conduction, and imaging studies. While magnetic resonance imaging is the current imaging modality of choice for BPI, ultrasound is a promising newcomer that is inexpensive, accessible, and available at point of care. OBJECTIVE: To evaluate ultrasound as a diagnostic tool in the assessment of traumatic adult BPI through a systematic review. METHODS: An electronic literature search was completed in MEDLINE, EMBASE, CINAHL, and Cochrane databases up to July 2016. Two independent reviewers completed the screening and data extraction. Methodological quality of studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Statistical analysis was used to estimate pooled sensitivities and study heterogeneity. RESULTS: Seven studies were included. Four studies compared the detection of pre- and postganglionic lesions at different levels (C5-T1) to surgical exploration as the reference standard. Sensitivity of lesion detection was greater in the upper and middle spinal nerves: C5 (93%, confidence interval [CI] = 78%-100%), C6 (94%, CI = 82%-100%), and C7 (95%, CI = 86%-100%) than in the lower: C8 (71%, CI = 36%-95%) and T1 (56%, CI = 29%-81%). CONCLUSION: Individual studies demonstrate ultrasound as an effective diagnostic tool for traumatic adult BPI. Sensitivity of lesion detection was noted to be greater in the upper and middle (C5-C7) than in the lower spinal nerves (C8, T1). Further standardized studies should be performed to confirm the utility of ultrasound in the diagnosis of traumatic adult BPI.

Validation of pharyngeal findings on sleep nasopharyngoscopy in children with snoring/sleep disordered breathing.

OBJECTIVE: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with snoring - sleep disordered breathing (S-SDB). DESIGN: Prospective agreement diagnostic study on retrospective data. METHODS: We conducted an inter-and intra-rater agreement study on video documentations of SNP performed on children (non-syndromic, complex, or operated upon) who presented with S-SDB. The videos featured various pharyngeal findings (normal, collapse, mixed or obstruction). Three 'non-expert' raters at various stages in their otolaryngological careers rated the videos independently, and on two separate occasions following an instructional session. We calculated both weighted and non-weighted linear kappa. RESULTS: Each independent observer rated sixty-one videos (2 weeks apart). Intra-observer agreement was 0.64 ± 0.08 (95% CI 0.48-0.81), 0.74 ± 0.07 (95% CI 0.60-0.88), 0.59 ± 0.08 (95% CI 0.43-0.74), for raters 1, two and three. Weighted kappa was 0.6 ± 0.1 (95% CI 0.41-0.79), 0.8 ± 0.06 (95% CI 0.7-0.92), 0.7 ± 0.07 (95% CI 0.57-0.83), respectively. Inter-rater agreements between raters one and two, two and three, three and four were 0.83 ± 0.06 (95% CI 0.71-0.95), 0.52 ± 0.08 (95% CI 0.36-0.70), and 0.53 ± 0.08 (95% CI 0.37-0.69), respectively. Weighted kappa was 0.83 ± 0.073 (95% CI 0.69-0.98), 0.68 ± 0.06 (95% CI 0.56-0.79), and 0.64 ± 0.07 (95% CI 0.49-0.78), respectively. CONCLUSIONS: This is the first validation of pharyngeal findings on SNP in children. It is based on a four types' classification. Overall reproducibility amongst the three raters and their agreement was moderate to good. Further work should be phase four trials investigating the impact on outcome.