Nasal Construction in Congenital Arhinia Due to Novel SMCHD1 Gene Variant.

Arhinia, or congenital absence of the nose, is an exceedingly rare anomaly caused by pathogenic variants in the gene SMCHD1 . Arhinia exhibits unique reconstructive challenges, as the midface is deficient in skeletal and soft tissue structures. The authors present 2 related patients with arhinia who harbor a novel SMCHD1 gene variant and illustrate their surgical midface and nasal construction. Targeted sequencing was carried out on DNA samples from the 2 affected patients, 1 anosmic and 1 healthy parent, to identify variants in exons 3 to 13 of SMCHD1 . The affected patients and anosmic parent were found to have a novel SMCHD1 gene variant p.E473V. A staged surgical approach was applied. First, both patients underwent a LeFort II osteotomy and distraction osteogenesis to improve the projection of the midfacial segment, followed by tissue expansion of the forehead, and nasal construction with a forehead flap that was placed over a costochondral framework derived from rib cartilage. The novel gene variant could guide future investigations on genetic pathways and molecular processes that underly the physiological and pathologic development of the nose. Further investigations on the variable expressivity ranging from anosmia to arhinia could improve clinical genetic screens for risk stratification of individuals with anosmia on passing on arhinia to their children. Due to the exceptional rarity and complexity of congenital arhinia, most surgical approaches are developed on a single-case basis. This case series, albeit limited to 2 cases, is the largest pedigree of such cases in the literature. It highlights key principles of a staged approach to nasal construction in arhinia and discusses nuances and improvements learned between both patients. It subsequently offers an optimized guide to this surgical strategy.

Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization.

BACKGROUND: The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand. METHODS: We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations. RESULTS: Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve. CONCLUSIONS: Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.

Evaluating and Comparing Emotional Intelligence and Improvement Mindset of Plastic Surgery Residents.

BACKGROUND: Emotional Intelligence (EI) has been linked to burnout, job satisfaction, and work performance among resident physicians. Individuals with a growth mindset believe intelligence and ability are traits that can be increased or improved upon through learning. EI and mindset have yet to be studied among plastic surgeons in the United States. MATERIALS AND METHODS: An online survey was distributed to plastic surgery residents and general surgery residents at a single institution containing a validated EI survey tool (TEIQue-SF). Second, a survey was sent to all plastic surgery residents in the United States containing the TEIQue-SF and a validated survey tool to assess mindset (ITIS). RESULTS: The response rate for the local study was 82% (plastic surgery) and 75% (general surgery). Only 7.8% of plastic surgery residents had any prior formal EI training or education. Mean global EI scores of local plastic surgery residents were higher than the normative population sample (P <0.0001). Plastic surgery and general surgery residents had similar EI scores. Integrated residents and junior plastic surgery residents had higher Well-Being scores compared to independent (P = 0.04) and senior residents (P = 0.04). Sixty-four plastic surgery residents completed the national survey. No correlation was found between EI and ITIS scores among the national plastic surgery resident cohort. CONCLUSION: Despite different work profiles, general surgery and plastic surgery residents may have similar EI profiles. Mindset does not appear to correlate to EI domains. Future studies will focus on how EI and mindset may develop over the course of residency training and their relationship to overall resident wellness.

Webinar during COVID-19 Improves Knowledge of Changes to the Plastic Surgery Residency Application Process.

BACKGROUND: The COVID-19 pandemic has significantly impacted residency application process for all specialties, including plastic surgery residency. Almost all plastic surgery residency programs have suspended visiting sub-internship rotations. This study quantifies the impact of a webinar through an analysis of poll questions and a post-webinar survey sent to all registered participants. METHODS: A dedicated webinar was organized and held by the Harvard Plastic Surgery Residency Training Program. All attendees were asked several poll questions during the webinar. The 192 participants were also sent a post-webinar survey. RESULTS: The response rate was 68.2% (n = 131). Respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with before the webinar (P < 0.001). Respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (P = 0.009). In addition, respondents who had not taken time off for research or for other endeavors during or after medical school were less confident about their chances to match at the start of the webinar (P = 0.034). CONCLUSIONS: An online webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery. Residency programs should consider webinars as a method to inform and assist medical students during the upcoming application season.

Intra-abdominal Deep Inferior Epigastric Vessel Course Does Not Preclude Successful DIEP Flap Breast Reconstruction.

We present 2 patients in whom the course of the deep inferior epigastric vessels was intra-abdominal during deep inferior epigastric perforator (DIEP) flap breast reconstruction. Preoperative computed tomography angiography gave no indication of an unusual pedicle location. In both cases, pedicle dissection was completed safely without bowel injury, and reconstruction was completed successfully. Reconstructive surgeons need not abandon DIEP flap reconstruction upon discovering that the deep inferior epigastric vessels are intra-abdominal. Unfortunately, computed tomography angiography imaging does not identify this variant preoperatively. The risk of postoperative ileus after intra-abdominal pedicle dissection may be higher than the risk after dissection of retrorectus deep inferior epigastric pedicles, and thus it is reasonable to consider the use of prophylactic mesh in these cases.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series.

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique. Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations. Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation. Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Initial Misidentification of Thumb Poroma by Shave Biopsy.

Poromas are benign adnexal neoplasms originating from the intraepidermal portion of sweat gland ducts. With the possibility of malignant transformation, accurate clinical diagnosis and treatment are crucial. Numerous reports of hand poroma lesions have been reported. We present an unusual case of a distal thumb poroma originally identified as a squamous cell lesion in a shave biopsy and eventually accurately identified after excisional biopsy. This report highlights the limitations of shave biopsy associated with soft tissue hand lesions and the need to consider poroma when evaluating a soft tissue lesion of the hand.

Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines.

BACKGROUND: Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites. METHODS: A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores. RESULTS: A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings. CONCLUSION: The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.

Mandible Fractures.

Mandible fractures account for a significant portion of maxillofacial injuries and the evaluation, diagnosis, and management of these fractures remain challenging despite improved imaging technology and fixation techniques. Understanding appropriate surgical management can prevent complications such as malocclusion, pain, and revision procedures. Depending on the type and location of the fractures, various open and closed surgical reduction techniques can be utilized. In this article, the authors review the diagnostic evaluation, treatment options, and common complications of mandible fractures. Special considerations are described for pediatric and atrophic mandibles.

Efficacy of Standard Costochondral Grafting in Patients With Bilateral Craniofacial Microsomia.

Craniofacial microsomia remains the second most common craniofacial deformity after cleft lip and palate. Mandibular pathology has been classically scored from type I to type III by the modified Pruzansky-Kaban classification. The authors report a case of a 5-year-old patient with Goldenhar syndrome and bilateral type III craniofacial macrosomia. The patient had absence of bilateral glenoid fossas, condyles, coronoids, and rami as well as hypoplasia of the symphysis, parasymphysis, and mandibular body. Reconstruction was performed using 2 costochondral rib autografts to reconstruct a ramus and assist in the development of a neo-glenoid fossa at the cranial base. An additional portion of costal rib graft was used to augment the deficient symphysis. The patient was placed in class III occlusion postoperatively using maxillo-mandibular fixation screws and heavy elastics. The bone grafts healed without complications with no evidence of ankylosis, nonunion, or resorption to date. For the most severe forms of craniofacial microsomia, costochondral grafting remains an effective initial technique for lengthening the hypoplastic mandible and providing a foundation for future distraction.

An Algorithmic Approach to the Surgical Treatment of Chronic Ischemia of the Hand: A Systematic Review of the Literature.

BACKGROUND: Chronic ischemia of the hand can lead to intractable pain, cold intolerance, and digital necrosis, affecting up to 4.8 percent of patients undergoing vascular surgery. Treatment of patients suffering from chronic hand ischemia, in particular, the subset of patients with a nonreconstructible distal arterial tree, can be a significant challenge for hand surgeons. The purpose of this systematic review is to analyze the outcomes of surgical therapies in an effort to define the efficacy of each intervention. The authors also revisit the treatment algorithm for nontraumatic chronic hand ischemia. METHODS: A systematic search of the literature published since 1990 in the PubMed/MEDLINE database was performed using keywords. Articles were eligible if they described clinical studies of human patients with nontraumatic chronic hand ischemia who underwent sympathectomy, arterial bypass, or venous arterialization. Pain improvement, wound healing, and new ulcerations were primary outcome measures. Primary patency rates and limb salvage data were also collected as primary outcome measures in the bypass and arterialization study arms. RESULTS: For sympathectomy, arterial bypass, and venous arterialization, pain relief was achieved in 89, 100, and 100 percent of patients, respectively; whereas wound healing occurred in 74, 93, and 75 percent, respectively. Postoperative ulcerations were 0, 3, and 8 percent, respectively. No secondary amputations were reported in these 33 studies. Complication rates were moderately high (2.1 to 30.8 percent). CONCLUSION: This systematic review confirms that sympathectomy, arterial bypass, and venous arterialization are efficacious treatments, and allows for an algorithmic approach to the surgical treatment of chronic hand ischemia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Weight loss over 48 months is associated with reduced progression of cartilage T2 relaxation time values: data from the osteoarthritis initiative.

PURPOSE: To assess whether changes in knee cartilage MR-based T2 relaxation times are associated with weight loss in individuals with risk factors for knee osteoarthritis (OA) compared with controls with stable weight. MATERIALS AND METHODS: One hundred twenty-seven individuals with risk factors for knee OA were studied: 62 subjects had a body mass index (BMI) decrease≥10% over 48 months and 65 controls had a BMI change <3%. Cartilage segmentation from five knee compartments at baseline and 48-month follow-up was performed, and T2 maps were generated. The association of change in T2 values over 48 months in the weight-loss group versus the control group was assessed using multiple linear regression models. RESULTS: Weight loss was associated with significantly smaller increases in cartilage T2 in the medial femoral condyle (P = 0.035) and overall medial compartment (P = 0.006) compared with the controls. In a subgroup analysis comparing weight-loss subjects who were obese (BMI≥30 kg/m(2) ) and overweight (BMI 25-30 kg/m(2) ) at baseline, obesity was associated with smaller increases in cartilage T2 values in the medial femoral condyle (P = 0.022), lateral femoral condyle (P = 0.015), patella (P = 0.002), and globally across all compartments (P = 0.002). CONCLUSION: A decrease in BMI of ≥ 10% was associated with a slower progression of T2 values in individuals with risk factors for OA, suggesting a beneficial impact of weight loss on cartilage matrix degeneration.

Six weeks of voluntary wheel running modulates inflammatory protein (MCP-1, IL-6, and IL-10) and DAMP (Hsp72) responses to acute stress in white adipose tissue of lean rats.

To prime local tissues for dealing with potential infection or injury, exposure to an acute, intense stressor evokes increases in circulating and local tissue inflammatory proteins. Regular physical activity facilitates stress-evoked innate reactivity and modulates the expression of inflammatory proteins in immuno-metabolic tissues such as white adipose tissue (WAT). The impact of regular physical activity on stress-evoked inflammatory protein expression in WAT, however, remains unclear. To investigate this question, lean male F344 rats (150-175g) were allowed voluntary access to a running wheel for 6weeks followed by exposure to an acute stressor (100, 1.5mA-5s inescapable tail shocks). Using ELISAs, corticosterone, heat shock protein 72 (Hsp72), macrophage chemoattractant protein (MCP-1), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1ß, IL-6, and IL-10 concentrations were measured in plasma and subcutaneous, intraperitoneal (epididymal and retroperitoneal WAT depots) and visceral (omental and mesenteric WAT depots) WAT compartments. Acute stress increased plasma concentrations of all proteins except TNF-α and, depending upon the compartment examined, WAT concentrations of MCP-1, IL-1ß, IL-6, and IL-10. Exercise ubiquitously increased IL-1ß within WAT, potentiated stress-evoked Hsp72 in plasma and WAT, and differentially increased stress-evoked MCP-1, IL-6, and IL-10 within WAT. These data suggest: (a) inflammatory proteins in non-obese WAT may serve compartment-specific immune and metabolic roles important to the acute stress response and; (b) voluntary habitual exercise may optimize stress-induced augmentation of innate immune function through increases in stress-evoked Hsp72, MCP-1, IL-6, and IL-10 and decreases in IL-1ß/IL10 and TNF-α/IL10 ratios within white adipose tissue.