Operative technique and management of central foot polydactyly.

Polydactyly is characterized by the manifestation of supernumerary digits in the hands and feet. It can be isolated or associated with a genetic syndrome. Based on the location of duplication, it is categorized as preaxial, postaxial, or central. The latter is a rare abnormality, comprising approximately 6% of cases. There is a paucity in the literature regarding this congenital anomaly and its overall management. Nonoperative treatment is generally unsuccessful in managing symptoms such as excessive width, abnormal digit alignment, and growth. Though surgical management addresses the individual patient's needs, general goals include preservation of digits with the greatest axial alignment, resection of symptomatic digits, alignment correction of the remaining great toe, stabilization of the soft tissues, and adequate soft tissue coverage. This study aims to delineate effective operative techniques for central foot polydactyly. Two patient cases are discussed, providing a framework for pre and postoperative care, complications, and outcomes. The techniques detailed offer a straightforward, efficacious, and safe method to reconstruct central foot polydactyly, returning form and function to the patient.

Surgical Treatment of Intercostal Brachial Nerve Pain after Mastectomy and Axillary Dissection.

Postmastectomy chronic pain describes chronic pain in the anterior aspect of the thorax, axilla, and/or upper half of the arm present after surgical treatment of breast cancer and persistent for more than 3 months. The most common cause of this syndrome is damage to the intercostal brachial nerve. Current methods of treatment include medications, physical therapy, and peripheral nerve blocks. The literature lacks data regarding surgical interventions for intercostal brachial nerve pain in the postmastectomy and axillary dissection breast cancer patient. We discuss a case of a 47-year-old woman with left breast cancer status post-nipple-sparing mastectomy and sentinel lymph node biopsy complicated by refractory dysesthesias in the intercostal brachial nerve distribution. Axillary exploration demonstrated a surgical clip with an associated neuroma of a branch of the intercostal brachial nerve. Excision and repair resulted in immediate pain relief in the postoperative period. We propose a comprehensive treatment algorithm to address postmastectomy pain attributed to intercostal brachial nerve pathology.

Musculoskeletal Pain Survey Outcomes in Cleft Surgeons and Orthodontists.

OBJECTIVE: Determine prevalence and characteristics of musculoskeletal pain and pathology in cleft providers. DESIGN: An IRB-exempt survey based on previously validated surveys was administered. Data collected included demographics, practice description, musculoskeletal pain history, formal diagnoses, and interventions. SETTING: Survey was sent to all cleft centers approved by the American Cleft Palate-Craniofacial Association worldwide. PATIENTS, PARTICIPANTS: All cleft surgeons and orthodontists at these centers met entry criteria. Eighty-three providers responded. Cleft center coordinators were unable to confirm the number of survey recipients. MAIN OUTCOME MEASURES: The hypothesis formulated prior to data collection was that prevalence would be comparable to general plastic surgeons and other at-risk health care providers. RESULTS: Average age of respondents was 49.8 ± 11.3 years; 33.9% of respondents were female. Average body mass index was 24.8 ± 3.5 kg/m2. Headaches were observed in 62.7% of surveyed respondents while musculoskeletal symptoms were reported in 89.8%. Of the 12 body parts addressed, most commonly affected were the neck (71.2%), shoulders (52.5%), and lower back (67.8%). Pain interfered with hobbies and home life in the majority of respondents (62.7%). Those who reported a formal diagnosis were more likely to undergo treatment including surgery (P < .01), medication (P = .03), and physical therapies (P < .01). CONCLUSIONS: Cleft surgeons and orthodontists experience a higher frequency of headaches compared to the general population, and musculoskeletal disorders are more prevalent than reported by general plastic surgeons. Pain interferes with hobbies and home life. Formal diagnosis leads to treatment. Preventative exercises and interventions are presented.

Management of Paronychia in Patients With Apert Syndrome.

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities-producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient's complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients' need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.

A Report on the Representation of Women in Academic Plastic Surgery Leadership.

BACKGROUND: The year 2017 marked the first year women comprised a majority of U.S. medical school matriculants. While more women are pursuing surgical training, within plastic surgery, there is a steady attrition of women advancing in leadership roles. The authors report the current status of women in academic plastic surgery, from trainees to chairwomen and national leadership positions. METHODS: The Electronic Residency Applications Service, San Francisco Match, National Resident Matching Program, Association of American Medical Colleges, American Council of Academic Plastic Surgeons, Plastic Surgery Education Network, and professional websites for journals and national societies were accessed for demographic information from 2007 to 2017. RESULTS: The number of female integrated pathway applicants remained stable (30 percent), with an increased proportion of female residents from 30 percent to 40 percent. There was an increase in female faculty members from 14.6 percent to 22.0 percent, an increase of less than 1 percent per year. Twelve percent of program directors and 8.7 percent of department heads were women. Nationally, major professional societies and administrative boards demonstrated a proportion of female members ranging from 19 percent to 55 percent (average, 27.7 percent). The proportion of female committee leaders ranged from 0 percent to 50 percent (average, 21.5 percent). Only six societies have had female presidents. No major journal had had a female editor-in-chief. The proportion of female editorial board members ranged from 1 percent to 33 percent (average, 16.1 percent). CONCLUSIONS: The authors' study shows a leak in the pipeline at all levels, from trainees to faculty to leadership on the national stage. This report serves as a starting point for investigating reasons for the underrepresentation of talented women in plastic surgery leadership.

Assessment of the Effect of Autograft Orientation on Peripheral Nerve Regeneration Using Diffusion Tensor Imaging.

PURPOSE: Given no definite consensus on the accepted autograft orientation during peripheral nerve injury repair, we compare outcomes between reverse and normally oriented autografts using an advanced magnetic resonance imaging technique, diffusion tensor imaging. METHODS: Thirty-six female Sprague-Dawley rats were divided into 3 groups: sham-left sciatic nerve isolation without injury, reverse autograft-10-mm cut left sciatic nerve segment reoriented 180° and used to coapt the proximal and distal stumps, or normally oriented autograft-10-mm cut nerve segment kept in its normal orientation for coaptation. Animals underwent sciatic functional index and foot fault behavior studies at 72 hours, and then weekly. At 6 weeks, axons proximal, within, and distal to the autograft were evaluated using diffusion tensor imaging and choline acetyltransferase motor staining for immunohistochemistry. Toluidine blue staining of 1-µm sections was used to assess axon count, density, and diameter. Bilateral gastrocnemius/soleus muscle weights were compared to obtain a net wet weight. Comparison of the groups was performed using Mann-Whiney U or Kruskal-Wallis H tests to determine significance. RESULTS: Diffusion tensor imaging findings including fractional anisotropy, radial diffusivity, and axial diffusivity were similar between reverse and normally oriented autografts. Diffusion tensor imaging tractography demonstrated proximodistal nerve regeneration in both autograft groups. Motor axon counts proximal, within, and distal to the autografts were similar. Likewise, axon count, density, and diameter were similar between the autograft groups. Muscle net weight at 6 weeks and behavioral outcomes (sciatic functional index and foot fault) at any tested time point were also similar between reverse and normally oriented autografts. CONCLUSIONS: Diffusion tensor imaging may be a useful assessment tool for peripheral nerve regeneration. Reversing nerve autograft polarity did not demonstrate to have an influence on functional or regenerative outcomes.

Evaluation of a Nerve Fusion Technique With Polyethylene Glycol in a Delayed Setting After Nerve Injury.

PURPOSE: Polyethylene glycol (PEG) has been hypothesized to restore axonal continuity using an in vivo rat sciatic nerve injury model when nerve repair occurs within minutes after nerve injury. We hypothesized that PEG could restore axonal continuity when nerve repair was delayed. METHODS: The left sciatic nerves of female Sprague-Dawley rats were transected and repaired in an end-to-end fashion using standard microsurgical techniques at 3 time points (1, 8, and 24 hours) after injury. Polyethylene glycol was delivered to the neurorrhaphy in the experimental group. Post-repair compound action potentials were immediately recorded after repair. Animals underwent behavioral assessments at 3 days and 1 week after surgery using the sciatic functional index test. The animals were sacrificed at 1 week to obtain axon counts. RESULTS: The PEG-treated nerves had improved compound action potential conduction and animals treated with PEG had improved sciatic function index. Compound action potential conduction was restored in PEG-fused rats when nerves were repaired at 1, 8, and 24 hours. In the control groups, no compound action potential conduction was restored when nerves were repaired. Sciatic functional index was superior in PEG-fused rats at 3 and 7 days after surgery compared with control groups at all 3 time points of nerve repair. Distal motor and sensory axon counts were higher in the PEG-treated rats. CONCLUSIONS: Polyethylene glycol fusion is a new adjunct for nerve repair that allows rapid restoration of axonal continuity. It effective when delayed nerve repair is performed. CLINICAL RELEVANCE: Nerve repair with application of PEG is a potential therapy that may have efficacy in a clinical setting. It is an experimental therapy that needs more investigation as well as clinical trials.

Prediction of Prolonged Ventilation after Coronary Artery Bypass Grafting: Data from an Artificial Neural Network.

OBJECTIVES: The need for mechanical ventilation 24 hours after coronary artery bypass grafting (CABG) is considered a morbidity by the Society of Thoracic Surgeons. The purpose of this investigation was twofold: to identify simple preoperative patient factors independently associated with prolonged ventilation and to optimize prediction and early identification of patients prone to prolonged ventilation using an artificial neural network (ANN). METHODS: Using the institutional Adult Cardiac Database, 738 patients who underwent CABG since 2005 were reviewed for preoperative factors independently associated with prolonged postoperative ventilation. Prediction of prolonged ventilation from the identified variables was modeled using both "traditional" multiple logistic regression and an ANN. The two models were compared using Pearson r2 and area under the curve (AUC) parameters. RESULTS: Of 738 included patients, 14% (104/738) required mechanical ventilation ≥ 24 hours postoperatively. Upon multivariate analysis, higher body-mass index (BMI; odds ratio [OR] 1.10 per unit, P < 0.001), lower ejection fraction (OR 0.97 per %, P = 0.01) and use of cardiopulmonary bypass (OR 2.59, P = 0.02) were independently predictive of prolonged ventilation. The Pearson r2 and AUC of the multivariate nominal logistic regression model were 0.086 and 0.698 ± 0.05, respectively; analogous statistics of the ANN model were 0.159 and 0.732 ± 0.05, respectively.BMI, ejection fraction and cardiopulmonary bypass represent three simple factors that may predict prolonged ventilation after CABG. Early identification of these patients can be optimized using an ANN, an emerging paradigm for clinical outcomes modeling that may consider complex relationships among these variables.

Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis.

BACKGROUND: Historically, complication rates after pressure ulcer reconstruction utilizing flap coverage have been high. Patients undergoing operations for pressure ulcer coverage typically have multiple risk factors for postoperative complications. The purpose of this study was to examine a large patient series in the pressure ulcer population to uncover objective evidence of the linkage between risk factors and outcomes after flap coverage. METHODS: This study was a retrospective chart review of patients who underwent flap reconstruction for a pressure ulcer between 1997 and 2015. The characteristics of patients were analyzed to determine those who had complications such as pressure ulcer recurrence, wound dehiscence, and wound infection. RESULTS: All patients (N = 276) underwent flap coverage of their pressure ulcers. The overall complication rate was 58.7% (162 patients). Wound dehiscence was the most common complication (31.2%), and the pressure ulcer recurrence rate was 28.6%. Multivariate regression for pressure ulcer recurrence revealed that body mass index <18.5 [relative risk (RR) 3.13], active smoking (RR 2.33), and ischial pressure ulcers (RR 3.46) were independent risk factors for pressure ulcer recurrence. Ischial pressure ulcers (RR 2.27) and preoperative osteomyelitis (RR 2.78) were independent risk factors for wound dehiscence. Diabetes was an independent risk factor for wound infection (RR 4.34). CONCLUSIONS: Our retrospective analysis revealed numerous factors that are associated with high rates of major postoperative complications. Risk factors must be taken into account when offering flap coverage, and risk-reducing strategies must be implemented in patients before pressure ulcer reconstruction.

Mass spectrometry comparison of nerve allograft decellularization processes.

Peripheral nerve repair using nerve grafts has been investigated for several decades using traditional techniques such as histology, immunohistochemistry, and electron microscopy. Recent advances in mass spectrometry techniques have made it possible to study the proteomes of complex tissues, including extracellular matrix rich tissues similar to peripheral nerves. The present study comparatively assessed three previously described processing methods for generating acellular nerve grafts by mass spectrometry. Acellular nerve grafts were additionally examined by F-actin staining and nuclear staining for debris clearance. Application of newer techniques allowed us to detect and highlight differences among the 3 treatments. Isolated proteins were separated by mass on polyacrylamide gels serving 2 purposes. This further illustrated that these treatments differ from one another and it allowed for selective protein extractions within specific bands/molecular weights. This approach resulted in small pools of proteins that could then be analyzed by mass spectrometry for content. In total, 543 proteins were identified, many of which corroborate previous findings for these processing methods. The remaining proteins are novel discoveries that expand the field. With this pilot study, we have proven that mass spectrometry techniques complement and add value to peripheral nerve repair studies.

New Innovations for Deep Partial-Thickness Burn Treatment with ACell MatriStem Matrix.

Objective: Burn injuries remain a large financial burden on the healthcare system. According to CDC statistics (2010), nonfatal and hospitalized burns in the U.S. cost $1.8 billion for an annual incidence of ∼486,000 cases. To date, no technique proves to be the ideal therapy of deep partial-thickness burns. In this study, we review a trial usage of ACell (ACell, Inc.) wound matrix on deep partial-thickness burns. Approach: Burn patients were admitted through the Vanderbilt Emergency Department. Three were consented to receive ACell therapy. Each patient suffered extremity burns, to which ACell MatriStem matrix was applied. Time to epithelialization and healing was monitored up to 1 month postintervention. Results: ACell MatriStem matrix use in deep partial-thickness burns enabled healing by 29 days on average without requiring autografts. The average total body surface area (TBSA) of injury was 7.2% with average TBSA treated with ACell equal to 2.5%. All burn sites underwent re-epithelialization after 5.6 days on average (range 4-7 days). Average length of stay after ACell placement totaled 2 days. All patients fully healed without the need for subsequent grafting or contracture development. No postoperative complications were noted. Innovation: To the extent of our knowledge, this is one of the first reported series to utilize ACell MatriStem product in deep partial-thickness extremity burns. Conclusion: Despite numerous products currently available for burn reconstruction, no one product embodies all the characteristics of an ideal graft. ACell biological extracellular matrix scaffolding appears promising, allowing for healing without use of an autograft.