Idiopathic Calcinosis Cutis of the Hand.

Calcinosis cutis is a disease process characterized by calcified lesions in the skin. Although there are five subtypes of calcinosis, idiopathic calcinosis cutis is a rare disease process with no clear etiology. It has been described in many parts of the body; however, there are only five reported cases specifically involving the hands. We describe the presentation and successful treatment of a case of idiopathic calcinosis cutis in a 65-year-old man with lesions on his bilateral hands. We believe that surgical excision of symptomatic lesions is a safe and effective treatment for idiopathic calcinosis cutis of the hands.

Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes.

Cranioplasty is a common surgical procedure used to repair cranial defects, and it is associated with significant morbidity and mortality. Although frailty is a strong predictor of poor postoperative outcomes across surgical specialties, little is known about frailty's impact on cranioplasty outcomes. This study examined the association between frailty and cranioplasty by comparing the effect of the Risk Analysis Index-Administrative (RAI-A) and the Modified Frailty Index-5 (mFI-5) on cranioplasty outcomes. Methods: The National Surgical Quality Improvement Program was queried for patients undergoing cranioplasty between 2012 and 2020. Receiver operating characteristics and multivariable analyses were used to assess the relationship of postoperative outcomes and the RAI-A, mFI-5, and increasing patient age. Results: There were 2864 included study patients with a median age of 57 years (IQR, 44-67), and a higher proportion of patients were women (57.0%) and White (68.5%). The RAI-A had a more robust predictive ability for 30-day mortality (C-Statistic, 0.741; 95% confidence interval (CI), 0.678-0.804) compared with mFI-5 (C-Statistic, 0.574; 95% CI, 0.489-0.659) and increasing patient age (C-Statistic, 0.671; 95% CI, 0.610-0.732). On multivariable analyses, frailty was independently associated with mortality and other poor postoperative outcomes (P < 0.05). Conclusions: The RAI-A demonstrated superior discrimination than the mFI-5 and increasing patient age in predicting mortality. Additionally, the RAI-A showed independent associations with nonhome discharge and postoperative complications (CDII, CDIIIb, and CDIV). The high rates of operative morbidity (5.0%-36.5%) and mortality (0.4%-3.2%) after cranioplasty highlight the importance of identifying independent risk factors for poor cranioplasty outcomes.

Geographic Trends in the Neurosurgery Match During the COVID-19 Pandemic.

In the present article, the impact of the COVID-19 pandemic on geographical trends in the neurosurgery match in successfully matched applicants was analyzed. A cross-sectional analysis for the years from 2017 to 2021 was performed. Successful applicants' region, state, and medical school were compared with the location of their matched residency program. The number of applicants matching at a residency program within the same region or state as their home medical school or their own medical school was then evaluated. One hundred fifteen neurosurgery residency programs and 1066 successfully matched applicants were included in the analysis. When comparing 2021 with previous years, no significant change in the percentage of applicants matching at their home region (43.1% vs 49.7%, P = .09), home state (25.1% vs 26.3%, P = .69), or home program (19.9% vs 18.7%, P = .70) was found. The COVID-19 pandemic did not significantly affect geographic trends during the neurosurgery match in 2021. This is of note as the COVID-19 pandemic significantly affected the match in other competitive specialties, including plastic surgery, dermatology, and otolaryngology. Despite limited away rotations, it is possible that neurosurgery programs did not change their applicant selection criteria and implemented systems to virtually interact with applicants outside of their local region.

The Impact of COVID-19 on the Orthopaedic Surgery Residency Match.

Introduction Matching into an orthopaedic surgery residency program presents a challenging accomplishment for applicants to achieve in any given year. Due to the profound changes to the application process caused by the coronavirus disease 2019 (COVID-19) pandemic it was theorized that there would be a change in the number of graduates matching close to their home medical school region, state, and program. Methods Orthopaedic surgery residency program Web sites and social media accounts were accessed to elucidate current resident data, including graduates' medical school, and geographical location of their school. Chi-square analysis was performed to identify trends in current residents matching within their home program, state, and region associated with the 2021 orthopaedic match. These numbers were compared with previous year's successful applicants. Results In 2021, a significant 4.4% ( p =0.02) increase in successful matches within applicants' home states occurred (33.4% vs. 37.8%) and home programs ( p <0.001) when compared with previous years (21.2% vs. 27.4%). However, in 2021, there was no significant change in home region matching ( p =0.56) with 60% of successful matches occurring in home regions. This was statistically consistent with what was observed in previous years (61.4%). Conclusion The COVID-19 pandemic was associated with restrictions in travel and interview options resulting in a significant increase in the number of orthopaedic applicants who matched into their home program, or at programs in their home state compared with previous years. Although no statistically significant regional change occurred during the 2021 match, it remains the leading predictor of where successful applicants will match. With many unknowns related to the upcoming match cycles it is important for applicants and programs to have a general idea of recent trends and outcomes to best focus their efforts, especially if diversity and minority inclusion are considered in highly competitive specialties like orthopaedic surgery.

Anomalous Presentation of Venous Malformations in an Adolescent Male.

Venous malformations (VMs) may manifest clinically in a broad spectrum. Most VMs are sporadic with previous studies reporting less than 1.2% to be inherited. Conversely, multifocal lesions, such as glomuvenous malformations (GVMs), which have glomus cells in their vascular walls, have been reported to have a frequency of inheritance of 63.8%. Both VMs and GVMs may occur due to sporadic mutation and must be differentiated clinically because this will dictate their proper treatment. Sporadic GVMs involve skin and subcutis, with bluish-purple coloration, are painful to compression, and have no radiographic evidence of phleboliths. Previous studies have demonstrated that VMs are almost always associated with a single lesion that is nontender to compression and are often able to be diagnosed by the presence of phleboliths on radiographic imaging. We present a case of a 14-year-old right-hand-dominant male who presented with two distinct VMs on the dorsum of the right index finger at the proximal and middle phalanges. A previously biopsied lesion overlying the ipsilateral olecranon, which was reported as a possible glomus tumor versus vascular malformation, was present as well. Based on history, physical examination, multicentric presentation, and radiographic findings, the presumptive diagnosis was that the lesions were GVMs. However, after surgical excision and histopathologic examination, the lesions were determined to be VMs because of the absence of glomus cells. Due to the difference in treatment modalities for VMs and GVMs, the ability to accurately diagnose these lesions clinically is essential. This case represents an anomalous presentation of multiple venous malformations occurring in two distinct locations in a 14-year-old boy.

Negative-Pressure Wound Therapy for Ludwig's Angina: A Case Series.

Negative-pressure wound therapy (NPWT) is a well-established therapeutic approach for various complex wound classes. There is currently limited information on the use of NPWT for the scope of head and neck wounds. However, NPWT has been used successfully in some cases, including malignancy, infection, and trauma. In West Virginia, the incidence of dental-related infections leading to Ludwig's Angina is high due to lack of access to dental care. Our case series describes the application of vacuum-based therapy in conjunction with antibiotic therapy for quick, effective closure of deep tissue infections before definitive complex wound repair via graft and flap reconstructions. Over a period of 3 months, 2 patients with submental infections extending to the lateral neck demonstrated clean, efficient wound closure with NPWT for less than 14 days while hospitalized at West Virginia University Medicine. Outpatient follow-up with these patients demonstrated excellent cosmetic outcomes with minimal contracture or hypertrophy of healing tissue. NPWT promotes wound healing through decreased edema, improved perfusion, and increased granulation of tissue based on our findings. Our series encourages the use of NPWT for initial closure of complex wounds secondary to deep neck infections.

Intravascular Papillary Endothelial Hyperplasia (Masson's Tumor) of the Hand.

A nonspecific soft tissue mass of the hand can be difficult to diagnose due to the multitude of possible etiologies. In this case, we discuss our experience in diagnosing and treating intravascular papillary endothelial hyperplasia, or Masson's tumor, of the hand. The wide range of differential diagnoses and the morphological resemblance to angiosarcoma make Masson's tumor an important clinical entity to understand. The purpose of this study is to familiarize the reader with the appropriate diagnostic and treatment modalities that allow the clinician to recognize Masson's tumor, differentiate it from similar clinical entities, and institute the appropriate management regimen.

Implications of Rheumatic Disease and Biological Response-Modifying Agents in Plastic Surgery.

The preoperative evaluation for any reconstructive or aesthetic procedure requires a detailed history of existing medical conditions and current home medications. The prevalence of rheumatic diseases such as rheumatoid arthritis, gout, and psoriasis is high, but the impact of these chronic illnesses on surgical outcome and the side effects of the powerful medications used for treatment are often underappreciated. In this review, the authors highlight key perioperative considerations specific to rheumatologic diseases and their associated pharmacologic therapies. In particular, the authors discuss the perioperative management of biological response-modifying agents, which have largely become the new standard of therapy for many rheumatic diseases. The literature reveals three key perioperative concerns with biological therapy for rheumatic disease: infection, wound healing delays, and disease flare. However, data on specific perioperative complications are lacking, and it remains controversial whether withholding biological therapy before surgery is of benefit. The risk of these adverse events is influenced by several factors: age, sex, class of biological agent, duration of exposure, dosage, onset and severity of disease, and type of surgical procedure. Overall, it remains best to develop an individualized plan. In younger patients with recent onset of biological therapy, it is reasonable to withhold therapy based on 3 to 5 half-lives of the specific agent. In older patients with a substantial history of rheumatic disease, the decision to discontinue therapy must be weighed and decided carefully in conjunction with the rheumatologist.

Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.

BACKGROUND: There is a growing concern for microbial resistance as a result of overuse of antibiotics. Although guidelines have focused on the use of antibiotics for surgery in general, few have addressed plastic surgery specifically. The objective of this expert consensus conference was to evaluate the evidence for efficacy and safety of antibiotic prophylaxis in plastic surgical procedures. METHODS: THE AUTHORS: searched for existing high-quality systematic reviews for antibiotic prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase databases. All synonyms for antibiotics were combined with terms for relevant plastic surgery procedures. The searches were not limited by language, and included all study designs. In addition, supplemental hand searches were performed of bibliographies of relevant articles, and extensive "related articles." Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons to reach consensus recommendations. RESULTS: Database searches identified 4300 articles, from which 2042 full-text articles were identified for eligibility. De novo meta-analyses were performed for each plastic surgical category. In total, 67 studies met the inclusion criteria, including nine for breast surgery, 17 for head and neck surgery, 10 for orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery, five for skin surgery, and two for abdominoplasty. CONCLUSIONS: Systemic antibiotic prophylaxis is recommended for clean breast surgery and for contaminated surgery of the hand or the head and neck. It is not recommended to reduce infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty.

CASE REPORT Successful Treatment of a Rare Massive Dabska Tumor.

OBJECTIVE: The Dabska tumor is a rare low-grade angiosarcoma first described in 1969 by Maria Dabska. Approximately 30 cases of varying presentations have been reported since its initial description. METHODS: We describe a case of a 23-year-old woman presenting with a massive recurrent left flank hemangioendothelioma, at final resection diagnosed to be an endovascular papillary angioendothelioma (Dabska tumor). The sheer size of the tumor necessitated reconstructive surgery. RESULTS: Successful abdominal reconstruction after radical resection of a Dabska tumor was achieved using local fasciocutaneous-type flaps. CONCLUSION: To our knowledge, this is the first case report describing reconstructive surgery following resection of an abdominal Dabska tumor.

Appearance is a function of the face.

BACKGROUND: Increasingly, third-party insurers deny coverage to patients with posttraumatic and congenital facial deformities because these are not seen as "functional." Recent facial transplants have demonstrated that severely deformed patients are willing to undergo potentially life-threatening surgery in search of a normal physiognomy. Scant quantitative research exists that objectively documents appearance as a primary "function" of the face. This study was designed to establish a population-based definition of the functions of the human face, rank importance of the face among various anatomical areas, and determine the risk value the average person places on a normal appearance. METHODS: Voluntary adult subjects (n = 210) in three states aged 18 to 75 years were recruited using a quota sampling technique. Subjects completed study questionnaires of demography and bias using the Gamble Chance of Death Questionnaire and the Rosenberg Self-Esteem Scale. RESULTS: The face ranked as the most important anatomical area for functional reconstruction. Appearance was the fifth most important function of the face, after breathing, sight, speech, and eating. Normal facial appearance was rated as very important for one to be a functioning member of American society (p = 0.01) by 49 percent. One in seven subjects (13 percent) would accept a 30 to 45 percent risk of death to obtain a "normal" face. CONCLUSIONS: Normal appearance is a primary function of the face, based on a large, culturally diverse population sample across the lifespan. Normal appearance ranks above smell and expression as a function. Restoration of facial appearance is ranked the most important anatomical area for repair. Normal facial appearance is very important for one to be a functional member of American society.

Intraoperative use of bupivacaine for tumescent liposuction: the Robert Wood Johnson experience.

BACKGROUND: Bupivacaine anesthetic is commonly used as a wetting solution additive in tumescent liposuction, but its routine use remains controversial because of a lack of evidence in the current literature. METHODS: In accordance with local institutional review board regulations, a retrospective chart review was conducted of liposuction cases performed from 1997 to 2007 at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. The primary endpoint was adverse perioperative events. Secondary endpoints included length of postanesthesia care unit stay and length of total postoperative hospital stay. RESULTS: Eighty-seven cases were analyzed and two subsets of patients were identified. In group 1, 24 patients were compared who underwent liposuction as the primary procedure and received bupivacaine, lidocaine, or no additive in their wetting solution. No adverse events were encountered and the average length of stay was not significantly different. In group 2, 20 patients were compared who underwent abdominoplasty and liposuction and received bupivacaine or no additive in their wetting solution. No adverse events occurred and patients receiving bupivacaine had a significantly shorter average length of stay, 19 hours versus 36 hours, compared with controls (p = 0.015). CONCLUSIONS: A review of the experience at Robert Wood Johnson University Hospital reveals that the intraoperative use of bupivacaine for tumescent liposuction in 27 cases appeared to be as safe as other tumescent additives. There did not appear to be a significant difference in the incidence of adverse events or postoperative length of stay for patients who underwent liposuction with bupivacaine compared with other wetting solutions. Among a subset of patients who underwent concurrent abdominoplasty and liposuction procedures, patients who received bupivacaine spent significantly less time in the hospital postoperatively than those who did not receive it. Conducting future prospective studies involving larger samples among multiple centers is an essential next step to confirm these findings.

Dermabond skin closures for bilateral reduction mammaplasties: a review of 255 consecutive cases.

BACKGROUND: 2-Octyl cyanoacrylate (Dermabond; Ethicon, Inc., Somerville, N.J.) has been available as a skin closure alternative or adjunct since 1997. The purpose of this study was to review a large series of 255 consecutive bilateral reduction mammaplasty patients to evaluate the safety and efficacy of Dermabond for these procedures. METHODS: A review was undertaken of 255 consecutive bilateral reduction mammaplasties performed by a single surgeon from 1999 to 2005 with Dermabond used for skin closure. This series of patients was compared with an earlier review by the same surgeon of 415 consecutive bilateral reduction mammaplasties using standard layered sutured skin closures. RESULTS: Dermabond was associated with decreased operative times compared with the sutured closures (93 minutes compared with 118 minutes; 25 minutes or 20 percent less time). The rates for minor wound dehiscence (1.18 percent), major wound dehiscence (0.78), hypertrophic scar revisions (2.75 percent), and cellulitis (2.75 percent) were all lower in the Dermabond group, but these differences were not statistically significant. CONCLUSIONS: Dermabond is a safe and effective means of skin closure for bilateral reduction mammaplasties. Shortened operative times can lead to economic health cost savings. Patient discomfort is minimized and postoperative care is simplified.

Maximizing outcomes in breast reduction surgery: a review of 518 consecutive patients.

BACKGROUND: Economic constraints and diminished healthcare resources mandate increased efficiency in labor-intensive plastic surgical procedures, such as reduction mammaplasty. The evolution to our current approach over a 9-year period was reviewed. METHODS: From 1992 to 2001 a total of 518 patients underwent bilateral reduction mammaplasty by a single plastic surgeon. Since 1992, a bilateral simultaneous approach to reduction mammaplasty was used, with the primary surgeon (Scott) performing the preoperative markings and determining the final resection. An inferior pedicle, "inverted T" technique using a Wise pattern was used for all cases. The initial 2-year period (113 consecutive patients from 1992 to 1994) was compared with the later 2-year period (103 patients from 1999 to 2001). Variables that decreased operative times and resources were identified. RESULTS: Length of stay (from admission to discharge) was initially 27 hours (overnight admission at a hospital) in the early review and decreased to 5 hours (outpatient surgery center) in the recent series. Drains were used in 100 percent of the earlier cases and in 7 percent in the recent series. Major complications occurred in 3 percent of the entire series. Minor complications occurred in 20 percent of all patients. In the recent series 97 percent of patients received complete relief of their preoperative symptoms and expressed satisfaction with their results. Operative times decreased from 120 to 102 minutes. Beginning in 1999, Dermabond skin adhesive was used in all patients. CONCLUSIONS: An evolutionary approach to bilateral reduction mammaplasty with low complication rates and high patient satisfaction is presented. Optimization of technique leads to decreased operative times, shortened lengths of stay, and contributes to efficient use of surgeon and operating room resources.

Frontal bone periosteal osteomas.

Osteomas are the most common tumors of the cranial vault and facial skeleton. Osteomas are usually benign in nature, commonly presenting with symptoms of facial deformity, facial pain, and headaches. Although the frontal sinus is the most frequent location of cranial osteomas, they are also occasionally seen involving only the frontal bone periosteum. This study is a retrospective series investigating the characteristics, management, and outcomes of five patients with frontal bone periosteal osteomas surgically treated with superficial osteotomies with primary closure. Medical charts were reviewed focusing on symptoms, size, radiographic findings, and disease of the periosteal osteomas. The chief complaint primarily involved a palpable deformity, which led to surgical evaluation. Radiographic studies were obtained to evaluate size and location of the frontal osteomas. Microanalysis of the specimens confirmed the presence of mature cancellous and/or cortical bone. Postoperative follow-up revealed no evidence of recurrence or complications. The superficial ostectomy technique with primary closure offers a simple, effective method for removal of frontal bone periosteal osteomas with minimal side effects.

Perceived functional impact of abnormal facial appearance.

Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with "normal" and "abnormal" congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.