Targeted Muscle Reinnervation: A Systematic Review of Nerve Transfers for the Upper Extremity.

INTRODUCTION/BACKGROUND: Despite inspiring improvements in postamputation pain and prosthetic control, targeted muscle reinnervation (TMR) continues to be underused. With some consistency for recommended nerve transfers developing in the literature, it is necessary to systematize these techniques and simplify their incorporation into routine amputation and neuroma care. This systematic review explores the coaptations reported in the literature to date. METHODS: A systematic review of the literature was performed to collect all reports describing nerve transfers in the upper extremity. The preference was directed toward original studies presenting surgical techniques and coaptations used in TMR. All target muscle options were presented for each nerve transfer in the upper extremity. RESULTS: Twenty-one original studies describing TMR nerve transfers throughout the upper extremity met inclusion criteria. A comprehensive list of transfers reported for major peripheral nerves at each upper extremity amputation level was included in tables. Ideal nerve transfers were suggested based on convenience and frequency with which certain coaptations were reported. CONCLUSIONS: Increasingly frequent studies are published with convincing outcomes with TMR and numerous options for nerve transfers and target muscles. It is prudent to appraise these options to provide patients with optimal outcomes. Certain muscles are more consistently targeted and can serve as a baseline plan for the reconstructive surgeon interested in incorporating these techniques.

Weight Control following Body Contouring Surgery: Long-Term Assessment of Postbariatric and Nonbariatric Patients.

BACKGROUND: Few reports of weight maintenance following body contouring (BC) surgery present weight measurements as percentage weight change, and most of these studies do not isolate BC to specific body areas. This study analyzed weight control in the trunk-based BC population and further compared BC outcomes in postbariatric and nonbariatric patients. METHODS: The authors performed a retrospective cohort study of consecutive postbariatric and nonbariatric patients who underwent trunk-based BC (abdominoplasty, panniculectomy, and circumferential lipectomy) from January 1, 2009, through July 31, 2020, at West Virginia University. A minimum 12-month follow-up was required for inclusion. With BC surgery date as the reference point, percentage total weight loss was assessed at 6-month intervals for 2 years following BC and every year thereafter. Change over time was compared between postbariatric and nonbariatric patients. RESULTS: Within the 12-year timeframe, 121 patients meeting criteria underwent trunk-based BC. Average follow-up from date of BC was 42.9 months. Sixty patients (49.6%) had previously undergone bariatric surgery. From before BC to endpoint follow-up, postbariatric and nonbariatric patients experienced a 4.39% ± 10.93% and 0.25% ± 9.43% increase in weight from baseline, respectively ( P = 0.0273). Once nadir weight loss was attained, weight regain occurred through endpoint follow-up in both groups (11.81% in the postbariatric cohort and 7.56% in the nonbariatric BC cohort; P = 0.0106). CONCLUSIONS: Long-term weight regain is common following trunk-based BC operations-specifically, in postbariatric patients. Although this should not contend with the psychological benefit of removing this excess tissue, it is important to report results with ideal weight metrics to optimally assess outcomes in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Demystifying Targeted Muscle Reinnervation: A Systematic Review of Nerve Transfers for the Lower Extremity.

Targeted muscle reinnervation (TMR) outcome studies reveal the benefit amputees experience and the potential functional improvement by optimizing neurocutaneous signaling for myoelectric prosthesis control. However, there are still many settings where these techniques are not offered to patients requiring lower extremity amputations or neuroma reconstruction. With growing consistency in the literature, it is helpful to systematize the nerve transfers described for lower extremity TMR and to simplify its integration into reconstructive care. Methods: A systematic literature review was performed and contained the following inclusion criteria: original cases of primary or secondary lower extremity amputation defects or nerve-related pain that underwent TMR with clearly described target muscles for each nerve transfer. Studies were excluded if the cases had been previously described or contained incomplete data. The primary outcomes were nerves transferred and muscles targeted. Target muscle options were presented in tables specific to anatomic region, and cross-sectional schematics were created for intraoperative assistance. Results: Seventeen studies presenting original cases with clearly described nerve transfers and target muscles in the lower extremity were included in the review. Target muscle selection for all nerve transfers at the transfemoral and transtibial levels were presented in separate tables. Conclusions: Reports of early experience at multiple institutions identify trends in the selection of certain target muscles for nerve transfers in transfemoral and transtibial TMR. Familiarity with these common target muscles and nerve transfers can simplify intraoperative decision-making and enhance integration of lower extremity TMR in amputation care and in the treatment of nerve-related pain.

Changes in Glucose Control and Lipid Levels Following Trunk-Based Body Contouring Surgery in Postbariatric and Nonbariatric Patients.

Background: Despite consistent interest over the past 2 decades regarding the metabolic effects of body contouring (BC), previous studies are limited by short follow-up periods, small sample sizes, gender-specific cohorts, and assessment of all anatomic regions together. Objectives: This study evaluates the changes in glucose and lipid levels over long-term follow up after trunk-based BC and compares postbariatric with nonbariatric patients. Methods: The retrospective cohort study included patients who underwent trunk-based BC from January 1, 2009 through July 31, 2020 at West Virginia University. A minimum 12-month follow up was required for inclusion. With BC surgery as the reference point, patients' glucose, hemoglobin A1c, and lipid levels were assessed prior to surgery and at long-term follow up. Change over time was compared between postbariatric and nonbariatric cohorts. Multivariable linear regression models were performed to assess the effect of potential confounding variables on the difference between cohorts. Results: Seventy-seven BC patients had glucose levels evaluated during the study period, and 36 had lipid profiles obtained. Average follow up from date of BC was 41.2 months for the patients with glucose follow up and 40.9 months for those with lipid levels. From pre-BC to endpoint follow up, glucose levels mildly increased in all patients. Multivariable linear regression models accounting for age showed nonbariatric patients experience significantly improved total cholesterol levels compared to postbariatric patients (P = 0.0320). Weight loss maintained following BC was not associated with significant differences between cohorts. Conclusions: Fasting glucose levels marginally increase in most BC patients through follow up. Nonbariatric patients generally experience more favorable changes in lipid profile following trunk-based BC than do postbariatric patients.

Principles of Fasciotomy Closure After Compartment Syndrome Release.

Acute compartment syndrome is a surgical emergency in the extremities resulting from increased compartmental pressure, requiring immediate fasciotomy to resolve muscular compromise. As the mainstay treatment, fasciotomies involve substantial skin incisions and are thus prone to complications such as skin necrosis, wound infection, and permanent disability. Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile. Several approaches are available to enhance outcomes of fasciotomy wounds, and a comprehensive knowledge of these options affords the treating surgeon greater flexibility and confidence in optimal management. Common techniques include early primary closure, gradual approximation, skin grafting, and negative pressure therapy. There is currently no consensus on the best method of closure. The purpose of this study was to review fasciotomy wound management from the time of initial release to final closure. Highlights include preparation for closing these wounds; the various techniques for fasciotomy closure, including adjunct options; evaluation of timing and staging; and injury-specific features, such as fracture management, limited subcutaneous tissues, and hand fasciotomies. Combining the perspectives of orthopaedic and plastic surgery, this review evaluates the benefits of multiple closure methods and highlights the importance of planning closure at the time of release.

Creating a Spaced Repetition Model to Supplement Education in Plastic Surgery.

Plastic surgery encompasses a wide spectrum of material involving comprehensive anatomy, physiology, microbiology, biomaterials, complex surgical techniques, and many nonsurgical interventions. The core disciplines overlap extensively with the foundational knowledge of many other surgical specialties. With the ever-expanding knowledge base required to become a competent plastic surgeon, spaced repetition is a means to optimize learning in plastic surgery and help trainees master new concepts while retaining other facts that are easily forgotten. Platforms for spaced repetition are user-friendly and can be synchronized between devices to streamline progress and make efficient use of the limited free time that exists throughout the workday. Flashcard decks can be imported to these platforms to follow a spaced repetition algorithm. Currently, no publicly available comprehensive deck exists for education in plastic and reconstructive surgery. Creation of flashcard decks covering lectures, textbooks, or old examination questions can reinforce the foundational concepts of our field. Additionally, there is potential to improve resident performance on the Plastic Surgery In-service Training Examination. Once created, this comprehensive flashcard deck can be distributed to plastic surgery residency programs to pave the way for a uniform curriculum.

US Public's Perceptions of Online Transformation Photos.

BACKGROUND: Although many plastic surgeons seek to optimize their online presence and reach a broader patient base, no studies to our knowledge have evaluated the general public's perceptions of one of the most valued informational tools: transformation photos. OBJECTIVES: The aim of this study was to evaluate the general public's preferences for viewing transformation photos online. METHODS: Respondents representative of the US public, crowdsourced through Amazon Mechanical Turk, answered a survey assessing perceptions of the posting of before-and-after photos. RESULTS: One thousand respondents completed the questionnaire. Ninety percent (905/1000) of respondents are willing to view online before-and-after photos. Sixty-three percent (634/1000) would consent to online posting of before-and-after photos of at least 1 body area, with comfort levels highest for facelift (36.4%), nonoperative facial rejuvenation (31.9%), liposuction (24.9%), and abdominoplasty (23.2%). Breast reduction (12.4%), breast reconstruction (10.9%), gluteal augmentation (14.0%), and vaginal rejuvenation (4.4%) are considered least acceptable for public posting. Respondents are significantly more opposed to online viewing of genitals than any other body area (P < 0.0001). Of those willing to have their own transformation photos posted online, 74.0% would allow posting on professional practice websites, 35.1% on Instagram, 26.6% on Facebook, 17.2% on Twitter, and 10.7% on Snapchat. Significantly more respondents prefer their transformation photos reside only on professional practice websites rather than on a social media platform (P < 0.0001). CONCLUSIONS: The public considers aesthetic facial procedures and body contouring most acceptable for showcasing transformation photos online. Although most respondents prefer viewing these photos on professional practice websites, Instagram is the favored social media platform. The majority of the public seek transformation photos when choosing a plastic surgeon for a cosmetic procedure.

#PlasticSurgery: A Comparative Deep Dive Analysis into Social Media and Plastic Surgery.

BACKGROUND: As social media have become pervasive in contemporary society, plastic surgery content has become commonplace. Two of the most engaging and popular platforms are Instagram and Twitter, and much research has been performed with respect to Twitter. Currently, there are no studies comparing and contrasting the two platforms. The aim of this study was to robustly sample plastic surgery posts on Twitter and Instagram to quantitatively and qualitatively evaluate platform content differences. METHODS: The hashtag #PlasticSurgery was systematically queried twice per day, for 30 consecutive days, on Twitter and Instagram. Account type, specific media content, possible patient-identifying information, content analysis, and post engagement were assessed. Post volume and engagement between Instagram and Twitter posts were compared. Post characteristics garnering high engagement from each platform were also evaluated. RESULTS: A total of 3867 Twitter posts and 5098 Instagram posts were included in this analysis. Daily total post volume for the 1-month duration of the study was significantly higher on Instagram compared with Twitter. Overall post engagement was significantly higher on Instagram compared with Twitter. Plastic surgeons and plastic surgery clinics represented the majority of accounts posting on both platforms with #PlasticSurgery. Identifiable patient features were much more prevalent on Instagram. The majority of Instagram posts were promotional in nature, outcome-based, or unrelated to plastic surgery. Alternatively, tweets were predominantly educational in nature. CONCLUSIONS: For physicians to harness the power of social media in plastic surgery, we need to understand how these media are currently being used and how different platforms compare to one another. This study has highlighted the inherent similarities and differences between these two highly popular platforms.

Kickstand External Fixator for Immobilization Following Free Flap Plantar Calcaneal Reconstruction.

Objective: Management of calcaneal wounds is challenging due to a paucity of tissue, complex local anatomy, and limited vascularity. These wounds are commonly associated with lower extremity fractures, which are often treated with external fixation. Free tissue transfers are frequently employed as a means for closure of plantar heel wounds; however, postoperative management can be challenging due to their dependent location. We sought to describe how simple modification of the external fixator can help relieve direct pressure, provide joint immobilization, and optimize accessibility necessary for flap survival. Methods: Three patients requiring autologous free tissue reconstruction of hindfoot defects were immobilized using an external fixator with a "kickstand" modification. Viability of the transferred tissue and the postoperative outcomes were assessed. Results: All free flaps survived with no associated complications. The "kickstand" modification was well tolerated with minimal discomfort. All 3 patients expressed satisfaction with early return to ambulation. Conclusion: An external fixator with a "kickstand" modification provides an essential function in maintaining the viability of the transferred tissue to plantar calcaneal wounds.

Nipple-Areolar Complex Reconstruction: A Review of the Literature and Introduction of the Rectangle-to-Cube Nipple Flap.

Objective: There are many approaches to nipple-areola complex reconstruction. Tissue quality and thickness, desired nipple location and size, scar position, and surgeon preference all play a role in selecting a technique. We present the rectangle-to-cube nipple flap, a new technique for challenging nipple reconstruction. A review of published techniques is compared and contrasted with this flap design. Methods: Following bilateral total skin-sparing mastectomies, a patient with breast cancer underwent breast reconstruction with tissue expanders and subsequent nipple reconstruction with the rectangle-to-cube nipple flap. An inferiorly based rectangular flap with medial and lateral extensions is designed inferior to the transverse scar. Upon elevation and rotation, the medial and lateral flaps form a cube. Results: In all cases of rectangle-to-cube nipple flaps performed at our institution, adequate nipple projection and patient satisfaction have been achieved at 2-month postoperative evaluation. Conclusion: The rectangle-to-cube nipple flap provides sustained nipple projection due to the de-epithelialized base on which the flap sits. The rectangle-to-cube nipple flap also takes advantage of a long transverse scar, and it can be extended to include longer scars for scar revisions.

The Danger Zone in the Anterior Neck: Anatomical Landmarks to Avoid Injury to Anterior Jugular Vein During Face-Lift and Neck-Lift.

Background: An estimated 125,711 face-lifts and 54,281 neck-lifts were performed in 2015. Regardless of the technique employed, facial and neck flap elevation carries with it anatomical risk of which any surgeon performing these procedures should be aware of. Statistics related to anterior jugular vein injury during these procedures have not been published. Objective: To define a "danger zone" that will contain both of the anterior jugular veins on the basis of anatomical landmarks to aid surgeons with planning their surgical approach during rhytidectomy in the anterior neck region. Methods: Ten fresh tissue heminecks were dissected. All specimens were dissected under loupe magnification in a 45° (face-lift) position in which a midline incision was used for exposure. Measurements from the anterior jugular vein to the hyoid, thyroid cartilage, and cricoid cartilage bilaterally were taken. The transverse distance between the anterior jugular veins at the level of the hyoid, thyroid cartilage, and cricoid cartilage was also measured. Results: The anterior jugular veins remain in an anatomical danger zone while they travel in the anterior neck. Regardless of anatomical variation of the vessels between bodies, they generally reside in this danger zone from their inferior emergence behind the sternocleidomastoid muscle until they branch in the suprahyoid region. Conclusions: Knowledge of the anatomy, course, and location of the anterior jugular veins through the anterior neck based on anatomical landmarks and distance ratios can facilitate a safer dissection during rhytidectomy procedures.

Preservation of the Sterile Matrix, Hyponychium, and Fingertip Pad in Fingertip Reconstruction With Composite Fingertip and Nail Bed Graft and Volar V-Y Advancement Flap.

Background: The goals of fingertip reconstruction are to achieve adequate soft-tissue coverage and a functional nail plate and to maintain sensation, proprioception, and cosmesis. Objective: We present a composite tissue graft and volar V-Y advancement flap for reconstruction of a traumatic amputation of a fingertip, which provided optimal preservation of the hyponychium and the volar pad for prevention of a hook nail. Historically, composite fingertip grafts have not been recommended for adults with large defects. Methods: The amputated nail bed, hyponychium, and a 10 × 20-mm segment of the fingertip were utilized as a composite graft for reconstruction of the nail bed in an adult. The addition of a volar V-Y advancement flap to reconstruct the fingertip was necessary for complete soft-tissue reconstruction. Results: The reconstruction resulted in nail plate adhesion without significant nail deformity and a functional and sensate fingertip. Conclusion: Components of amputated fingertips including the sterile matrix, hyponychium, and part of the fingertip can be utilized in a composite graft to yield satisfactory functional and cosmetic results in adults.