Capsular pneumatosis: A rare radiographic sign for internal breast implant capsule violation in trauma.

Breast augmentation is considered one of the most commonly performed procedures by aesthetic plastic surgeons, representing 16 % of all global plastic surgery procedures in 2020. Given the fact that thoracic trauma comprises over 20 % of trauma worldwide, it is unsurprising that there is potential for overlap between these two patient populations. Here, we present the case of a 59-year-old patient who had undergone bilateral breast augmentation over 10 years prior to presentation. They arrived as a highest-level trauma activation after being a helmeted cyclist struck by a motor vehicle resulting in significant left-sided thoracic trauma. Following stabilization in the trauma bay, CT imaging of the thorax demonstrated multifocal left pulmonary contusions and lacerations, multiple left-sided rib fractures (ribs 2-12), a small left pneumothorax, and left-sided subcutaneous emphysema. Imaging also demonstrated the presence of bilateral breast implants with the left implant appearing irregular in shape with the retropectoral space corresponding to the implant capsule having evidence of significant free air (capsular pneumatosis) concerning for acute traumatic rupture of the capsule. While undergoing surgical stabilization of her left-sided rib fractures, one of her ribs was noted to have violated the posterior wall of the breast capsule. Upon implant removal, the implant was found to have ruptured with tears in the shell corresponding to patient's rib fractures. This case represents a rare and unexpected complication of traumatic rib fractures; mainly the traumatic rupture of a silicone breast implant, which was identified by the presence of capsular pneumatosis on CT imaging. Presence of this rare radiographic sign (capsular pneumatosis) in the setting of a patient who has undergone breast augmentation should raise concern for possible implant rupture and capsule violation, even in the absence of external signs of penetrating injury.

Acute Isolated Thenar Compartment Syndrome in a Patient with Evans Syndrome: A Case Report.

INTRODUCTION: Acute compartment syndrome of the hand is a rare medical emergency, most often associated with trauma or fracture. CASE REPORT: Here, we describe a rare case of isolated thenar compartment syndrome of the hand in the absence of major trauma as the presenting symptom of pancytopenia due to Evans syndrome, an uncommon autoimmune hematologic disorder. CONCLUSION: In cases of atraumatic compartment syndrome, it is critical to evaluate for underlying coagulopathy in patients presenting to the emergency department.

Pleomorphic Adenoma of the Eyebrow: An Unexpected Finding and Review of Unusual Periorbital Soft Tissue Lesions.

ABSTRACT: Soft tissue lesions of the eyebrow are common and are usually diagnosed as dermoid cysts, pilomatrixomas, inclusion cysts, or basal cell carcinomas. Pleomorphic adenomas are benign glandular lesions most commonly found in the parotid gland or salivary glands, and less commonly found in the lacrimal gland. Here the authors report the case of a 35-year-old male who presented with a prominent soft tissue lesion of his right upper brow. This had been present for several months and had not substantially changed in size. Operative excision was performed via a supratarsal crease incision. The mass was located in a deep, periosteal plane, similar to a dermoid cyst. Final pathology demonstrated a 1.1 × 1.0 × 0.9 cm pleomorphic adenoma without defining characteristics of either the lacrimal gland or the minor adnexal glands of the skin or subcutaneous tissue. The authors reviewed the current literature on unusual lesions of the periorbital and brow regions, and the authors present aggregate data regarding epidemiology, diagnosis, and management.

Recurrent carpal tunnel syndrome associated with extension of flexor digitorum muscle bellies into the carpal tunnel: A case series.

While the success or failure of carpal tunnel release ultimately depends on the interplay of a wide array of factors, a broad understanding of the normal anatomy of the carpal tunnel accompanied by awareness of the possible variations of the individual structures that make up its contents is crucial to optimizing surgical outcomes. While anatomic variants such as extension of the flexor digitorum muscle bellies have been described as a cause of primary carpal tunnel syndrome (CTS), there have been no reports depicting its association with recurrent CTS following initially successful carpal tunnel release, a finding with potentially significant prognostic implications that can aid in operative planning. In such cases where muscle extension is identified preoperatively, careful debulking of the muscle belly may be beneficial in improving long-term surgical outcomes.

Remote Digital Preoperative Assessments for Cleft Lip and Palate May Improve Clinical and Economic Impact in Global Plastic Surgery.

OBJECTIVE: Reconstructive surgical care can play a vital role in the resource-poor settings of low- and middle-income countries. Telemedicine platforms can improve the efficiency and effectiveness of surgical care. The purpose of this study is to determine whether remote digital video evaluations are reliable in the context of a short-term plastic surgical intervention. SETTING: The setting for this study was a district hospital located in Latacunga, Ecuador. PATIENTS: Participants were 27 consecutive patients who presented for operative repair of cleft lip and palate. MAIN OUTCOME MEASURES: We calculated kappa coefficients for reliability between in-person and remote digital video assessments for the classification of cleft lip and palate between two separate craniofacial surgeons. We hypothesized that the technology would be a reliable method of preoperative assessment for cleft disease. RESULTS: Of the 27 (81.4%) participants, 22 received operative treatment for their cleft disorder. Mean age was 11.1 ± 8.3 years. Patients presented with a spectrum of disorders, including cleft lip (24 of 27, 88.9%), cleft palate (19 of 27, 70.4%), and alveolar cleft (19 of 27, 70.4%). We found a 95.7% agreement between observers for cleft lip with substantial reliability (κ = .78, P < .01). There was an 82.6% agreement between observers for cleft palate, with a moderate interrater reliability (κ = .55, P = .01). We found only a 47.8% agreement between observers for alveolar cleft with a nonsignificant, weak kappa agreement (κ = .06, P = .74). CONCLUSIONS: Remote digital assessments are a reliable way to preoperatively diagnose cleft lip and palate in the context of short-term plastic surgical interventions in low- and middle-income countries. Future work will evaluate the potential for real-time, telemedicine assessments to reduce cost and improve clinical effectiveness in global plastic surgery.

Can a Quality Collaborative Build Value in Global Surgery? Results From a Single State Experience.

BACKGROUND: Surgery is a critical component of global health care worldwide. Little is known about global surgery participation among surgeons in Connecticut. The goal of this pilot survey project was to determine the breadth of global surgery experience in our state. STUDY DESIGN: An electronic survey was distributed to surgeons in the state of Connecticut via the Connecticut Chapter of the American College of Surgeons (CTACS) and to departments of surgery throughout the state. RESULTS: Seventy-four surgeons and surgical residents completed the online survey from 17 different hospitals. Nineteen (25.7%) of the respondents had participated in global surgery. Most participated in yearly (56.3%), short-term experiences (94.5%). Nearly half of this group reported no formal record of outcomes (52.9%), but 17/19 (89.5%) respondents reported that accurate outcomes measures are beneficial to surgical care in resource-poor areas. Eighty-nine percent reported a willingness to participate in a surgical quality and outcomes database. CONCLUSION: A substantial proportion of surgeons in Connecticut participate in global surgery. Most surgeons value qualityin surgical care, yet outcomes are not routinely measured. This discordance may be addressed through the development of a quality improvement collaborative for global surgery.

The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings.

BACKGROUND: The development of surgery in low- and middle-income countries has been limited by a belief that it is too expensive to be sustainable. However, subspecialist surgical care can provide substantial clinical and economic benefits in low-resource settings. The goal of this study is to describe the clinical and economic impact of recurrent short-term plastic surgical trips in low- and middle-income countries. METHODS: The authors conducted a retrospective review of clinic and operative logbooks from Hands Across the World's surgical experience in Ecuador. The authors calculated the disability-adjusted life-years averted to estimate the clinical impact of cleft repair and then calculated the economic impact of surgical intervention for cleft disease. RESULTS: One thousand one hundred forty-two reconstructive surgical cases were performed over 15 years. Surgery was most commonly performed for scar contractures [449 cases (39.3 percent)], of which burn scars comprised a substantial amount [215 cases (18.8 percent)]. There were 40 postoperative complications within 7 days of operation (3.5 percent), and partial wound dehiscence was the most common complication [16 of 40 (40 percent)]. Cleft disorders constituted 277 cases (24.3 percent), and 102 cases were primary cleft lip and/or palate cases. Between 396 and 1042 total disability-adjusted life-years were averted through surgery for these 102 cases of primary cleft repair. This translates to an economic benefit between $4.7 million (human capital approach) and $27.5 million (value of a statistical life approach). CONCLUSIONS: Plastic surgical disease is a significant source of morbidity for patients in resource-limited regions. Dedicated programs that provide essential reconstructive surgery can produce substantial clinical and economic benefits to host countries.

International efforts in plastic surgery: the Hartford Hospital, Connecticut Children's Medical Center and University of Connecticut experience in Ecuador.

UNLABELLED: Plastic and reconstructive surgery provide a necessary and essential service to public health efforts in resource-poor regions around the world. Disease processes amenable to plastic surgical treatment significantly contribute to worldwide disability, and it is the poor and underserved who are disproportionately affected. METHODS: We conducted a week-long plastic and reconstructive surgical trip to Latacunga, Ecuador to provide reconstructive surgical services for the underserved in this region. RESULTS: Over the course of a week, 97 patients received surgery. Most patients were young (mean age = 21.8 years) and 50.5% were female. Burns and burn scar contractures were the most common diagnoses requiring surgery(21.6%), but cleft lip and palate deformities, scars, nevi, and congenital ear deformities comprised a significant proportion of the case load as well (17.5%, 11.3%, 12.4%, and 10.3%, respectively). There was one postoperative complication requiring reoperation. CONCLUSION: This short-term surgical trip successfully delivered essential reconstructive surgical care to an underserved population in rural Ecuador. Although this is most certainly only a fraction of the true surgical disease burden within this population, our experience provides a testament to the need for essential reconstructive surgical services in developing nations around the world.

Pseudoaneurysm in the hand of a three-year-old boy: a case report.

BACKGROUND: Post-traumatic, true aneurysm of the hand is a well-documented phenomenon. Hypothenar hammer syndrome is often a consequence of repeated blunt trauma to the palm, but a false aneurysm, or pseudoaneurysm, of the palm is much rarer. A pseudoaneurysm is often the result of focal penetrating trauma. OBJECTIVES: The goal of this article is to describe a rare case of a child with a pseudoaneurysm of the superficial palmar arch and his subsequent surgical treatment. CASE REPORT: A 3-year-old boy sustained an accidental laceration to his palm while picking up a knife from a counter. The child was initially treated in a local Emergency Department (ED) with local wound care and Dermabond (Ethicon, Inc., Somerville, NJ). No imaging was undertaken at that time. The boy subsequently developed a large, pulsatile, painful mass in his palm near the site of injury, and he presented to our ED for evaluation. Using a combination of imaging modalities and a careful history, the boy was accurately diagnosed with a pseudoaneurysm of the superficial palmar arch. This lesion was subsequently successfully resected and repaired. The child has healed well after surgery, with no lasting sensory or motor deficits to the hand. To date, this is one of only two reported post-traumatic pseudoaneurysms of the palmar arch in a child in North America. CONCLUSION: Although a rare phenomenon, pseudoaneurysm of the superficial palmar arch after local penetrating trauma remains an important item on the differential for patients presenting with palmar masses. Pseudoaneurysm can be effectively diagnosed and treated with excellent results.

Development of vaginal erosion and vesicocutaneous fistula following midurethral transvaginal tape with PelviLace for treatment of stress urinary incontinence.

Stress urinary incontinence (SUI) is a common diagnosis that greatly impacts quality of life for many women. Current therapies implement the use of suburethral slings, either synthetic or xenografts, to remedy this condition. In this study, we report on a patient with SUI, treated with PelviLace Biourethral Support, who suffered multiple issues postoperatively.

Fluoroscopic radiation burn after embolization of a spinal arteriovenous malformation.

Fluoroscopic radiation burns are being reported with increasing frequency because of the rise in number and duration of procedures performed under fluoroscopic guidance. We report a fluoroscopic radiation burn to a patient's back after three separate attempts to embolize a symptomatic spinal arteriovenous malformation, requiring fasciocutaneous flaps to ultimately close the wound. Risk factors, physiology, and modifications to decrease fluoroscopic radiation burns are discussed.

Snowblower injuries to the hand: epidemiology, patterns of injury, and strategies for prevention.

Snowblowers injure approximately 5000 people a year and can cause devastating hand injuries. Even with added safety measures and warnings on modern snowblowers, hand injuries are still occurring at an alarming rate. We have reviewed our series of snowblower-related hand injuries to elucidate the epidemiology, patterns of injury, and strategies for prevention.Questionnaires and treatment records of 22 individuals with snowblower injuries to the hand between 2002 and 2005 were reviewed. All patients were treated by a single hand surgeon at Hartford Hospital in Hartford, CT.Eleven of the 22 held upper level educational degrees. Averaged results include operator experience of 15.17 years, machine age of 21.38 years, temperature of 29.05 degrees F (-1.51 degrees C), precipitation of 8.60 cm (3.38 in), and duration of use of 20.59 minutes excluding 3 outliers. Three patients consumed 1 alcoholic drink and 1 consumed 2 alcoholic drinks before injury. The majority of patients were aware of safety warnings (77.20%) and injured themselves with the machine running (82.35%) resulting in multiple digit injury (2.0 on average) on the dominant hand (68.18%).Operator inexperience, low operator intelligence, and excessive alcohol consumption do not seem to contribute to injury. Instead, significant experience, older machines, short durations of use before injury, characteristic weather patterns, and underlying misperceptions about snowblower design and function typically set the stage for injury. Injuries may be prevented in the future by improving snowblower design and/or by making brief public service announcements.

Epulis gravidarum manum: pyogenic granuloma of the hand occurring in pregnant women.

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular tumor of the skin and mucous membranes. Whereas the literature describes pyogenic granulomas of pregnancy as occurring mainly within the gingival or oral mucosa, we present 5 cases of a histologically confirmed pyogenic granuloma on the hands of gravid women, each with no history of antecedent trauma. These tumors failed to resolve spontaneously postpartum necessitating surgical removal. We propose the term epulis gravidarum manum to describe this skin lesion.

Giant lipomas of the upper extremity.

Lipomas are slow-growing soft tissue tumours that rarely reach a size larger than 2 cm. Lesions larger than 5 cm, so-called giant lipomas, can occur anywhere in the body but are seldom found in the upper extremities. The authors present their experiences with eight patients having giant lipomas of the upper extremity. In addition, a review of the literature, and a discussion of the appropriate evaluation and management are included.

Bilateral symptomatic supernumerary muscle belly syndrome.

A 32-year-old woman with a longstanding history of bilateral forearm pain had been unable to open her fingers and use her left arm (treated as reflex sympathetic dystrophy) since the age of 14. On physical examination there was fullness and tenderness of the distal volar forearms bilaterally; the quadriga test (when the patient was asked to make a tight fist quickly, with one finger fully extended passively) elicited burning pain. Operation confirmed that she had anomalous reversed forearm muscles bilaterally, and these were successfully resected.