Anterior Ear Reconstruction with the Posterior Pull-through Flap.

Background: Defects of the central ear after skin cancer removal remain a common problem for the reconstructive surgeon. The experience with a one-stage, postauricular, skin-island flap passed through the cartilage to reconstruct ear defects is reported. Methods: Patients with an intact ear helix and an anterior full-thickness defect (cartilage defects included) were reconstructed with a skin-island flap based on posterior subcutaneous tissue deep to the flap base. The flap was passed through a generous aperture created in the ear cartilage. The skin at the base was incised superficially after the flap was passed through the cartilage to create a skin-island and avoid burial of epithelium. The flap periphery and postauricular harvest site were sutured with absorbable chromic sutures. Results: Twenty-two patients (six women, 16 men) with ear defects underwent single-stage reconstruction over a 9-year period. The defects reconstructed measured in diameter from 2 cm to 4.5 cm. Six patients required a second skin flap from the preauricular area to close ear canal defects. The pull-through flap added structural support, and prevented ear distortion. No flap necrosis occurred. Venous congestion was common and self-limiting. No epithelial cysts developed. Conclusions: A one-stage postauricular skin-island flap can reliably reconstruct anterior ear defects without distorting shape or position of the ear. Care is needed to provide a generous aperture through the ear cartilage to accommodate the flap. Healing proceeds predictably, and minimal complications are associated with this posteriorly-based, pass-through, skin-island flap in ear reconstruction.

Can Mentorship Shatter the Glass Ceiling in Academic Microsurgery? A National Survey of Microsurgery Fellowship-Trained Women.

BACKGROUND: The "leaky pipeline" phenomenon has caused women to remain underrepresented at higher levels of academic plastic surgery. No study has considered the availability of mentorship within any subset of academic plastic surgery. The purpose of this study was to evaluate the current representation of women in academic microsurgery and to determine the impact of mentorship on career progression. METHODS: An electronic survey was designed to determine the availability and quality of mentorship respondents received at different stages of their career (from medical student to attending physician). The survey was distributed to women who completed a microsurgery fellowship and were current faculty at an academic plastic surgery program. RESULTS: Twenty-seven of 48 survey recipients participated (56.3% response rate). Most held an associate professor (20.0%) or assistant professor (40.0%) position. Respondents had an average of 4.1 ± 2.3 mentors throughout their entire training. A minority of mentors were microsurgery trained (28.3%), and only 29.2% of respondents reported female mentorship throughout their training. Attending physicians least often received formative mentorship (52.0%). Fifty percent of respondents sought female mentors, citing that they desired female insight. Of those who did not seek female mentors, 72.7% cited a lack of access to female mentors. CONCLUSIONS: Evidenced by female trainees being unable to find female mentors and low rates of mentorship at the attending physician level, there is currently not enough capacity to meet the demand for female mentorship by women pursuing academic microsurgery. Many individual and structural barriers to quality mentorship and sponsorship exist within this field.

Modern Approaches to Pedicled Latissimus Dorsi Flap Breast Reconstruction with Immediate Fat Transfer.

The latissimus dorsi flap with immediate fat transfer is a viable option for fully autologous breast reconstruction in patients who are not candidates for free flap reconstruction. Technical modifications described in this article allow for high-volume and efficient fat grafting at the time of reconstruction to augment the flap and mitigate complications associated with the use of an implant.

Evaluating the Role of Mentorship in Career Advancement: A Survey of Women in Academic Hand Surgery.

PURPOSE: Despite the increasing percentage of women within the American Society for Surgery of the Hand, women remain underrepresented within leadership in academic hand surgery. Although this disparity in leadership representation may be improving, we aimed to investigate the role mentorship plays in advancing women in academic hand surgery. METHODS: This is a survey-based, mixed-methods study. A written survey assessing themes in personal and professional experiences with mentorship was sent to hand fellowship-trained women. Inclusion criteria were the completion of a hand fellowship and current affiliation with an academic institution. An evolved grounded theory framework was used to evaluate the responses. Themes were identified based on common responses. RESULTS: Of 186 eligible participants, 144 (85.2%) received the survey. The response rate was 48.6%. Respondents indicated that residency was the stage at which mentorship was most impactful (n = 25, 37%), and half of the respondents identified their desire to work in academic hand surgery during residency (n = 35, 50%). Obstacles to finding a mentor included lack of availability (n = 46, 67.7%), hesitance in searching for a mentor (n = 16, 23.5%), and searching for a mentor within an environment that was not conducive to success for trainees (n = 7, 10.3%). Most (84%) cited instances were the ones having the advice of a woman mentor was more impactful than that of a mentor who is a man. The reported need for same-sex mentorship fell into three categories: (1) insight into shared experiences, (2) assistance with conflict/bias management, and (3) support during career navigation. CONCLUSIONS: The findings of this study demonstrate the need for high-quality mentorship during the residency with a specific emphasis on same-sex mentorship. CLINICAL RELEVANCE: Our findings provide clear objectives related to improving access to and quality of mentorship. This foundational understanding will enrich mentor-mentee relationships, allowing for greater personal and professional success and satisfaction for both parties.

A Look Back: A Single Surgeon's Experience Using Virtual Surgical Planning in Adult Orthognathic Surgery.

The evolution of virtual surgical planning (VSP) in the last 2 decades has led to improved precision and efficiency for orthognathic surgery, both pre- and intraoperatively. This study evaluates a single surgeon's experience with this technology over the past 6 years. Patients undergoing orthognathic surgery using VSP with the senior author between 2015 and 2021 were retrospectively reviewed. Virtual surgical planning -specific data including incidence of midline/cant correction, occlusal equilibration, serial splints, segmental osteotomies, and custom plates were recorded and analyzed. Sixty patients undergoing orthognathic surgery using simulated VSP in the study period were retrospectively reviewed. Mean age at time of surgery was 23.5±7.9 years. Forty-nine patients (81.7%) underwent LeFort I osteotomy combined with at least 1 additional procedure (eg,unilateral or bilateral sagittal split osteotomy, condylectomy, genioplasty, etc.). Twenty-six (43.3%) of patients in the studied cohort underwent maxillary midline correction, 30.0% required occlusal equilibration, 36.7% underwent maxillary molar cant correction, 30.0% underwent mandibular cant correction, and 21.7% required both maxillary and mandibular cant correction. Three patients required serial splinting, and 15 patients (25.0%) required modification of splint design. Custom plates were utilized in 15 patients (25.0%). This study demonstrates the utility of VSP in accurately detecting occlusal cants, asymmetry, and occlusal interferences. Virtual surgical planning also allows for a dynamic preoperative planning process, offering the surgeon a high degree of versatility in splint design, and the ability to fabricate multiple customized splints for each case. This is particularly useful in patients with limited or unpredictable soft tissue elasticity.

A 10-Year Retrospective Review of the Nonsurgical Treatment of Infant Ear Anomalies.

BACKGROUND: A review of a single surgeon's 10-year experience treating congenital ear anomalies using nonsurgical ear molding is presented. This study assesses the efficacy of treating a variety of anomalies in infants with age ranging from younger than 1 week to 22 weeks and identifies potential barriers to care. METHODS: A retrospective chart and photographic review of 246 consecutive infants treated with ear molding between 2010 and 2019 was undertaken. Data regarding patient demographics, anomaly classification, device selection, treatment duration, adverse events, and satisfaction with outcomes were collected. RESULTS: This study included 385 infant ear anomalies in 246 patients. Median age at initiation of treatment was 16 days and median treatment duration was 29.5 days. A median number of three devices was needed to complete bilateral treatment. Treated anomalies included mixed deformity, helical rim, prominent, lidding/lop, Stahl ear, conchal crus, cupping, and cryptotia. Complications occurred in 47 patients, with skin breakdown being the most common [26 patients (55.3 percent)]. Satisfaction rate was 92 percent in 137 surveyed parents. Median patient household income was approximately $112,911, and treatment was covered by insurance for 244 of 246 patients. CONCLUSIONS: The study outcomes demonstrate that ear molding can be effective in patients as old as 22 weeks without compromising treatment duration or complexity. In addition, in the authors' experience, molding is an effective treatment for the majority of infant ear deformities. Despite a steady increase in patient volume over the past 10 years and consistent coverage of treatment by insurance, the authors' catchment area continues to be largely limited to affluent households. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Incorporating the Osseous Genioplasty Into Rejuvenation of the Lower Face.

BACKGROUND: The chin plays a critical role in the shape, projection, and soft tissue support of the lower face. Osseous genioplasty is a powerful tool in facial rejuvenation as it allows for optimal control of the resulting chin dimensions and improvement in submental and submandibular laxity. Osseous genioplasty can be used alone or in combination with other facial rejuvenation procedures to achieve an optimal result. OBJECTIVES: The aim of this study was to present the senior author's approach to skeletal analysis of the lower facial third and propose an algorithm that can be used to optimize skeletal support of the overlying soft tissue laxity while maintaining an aesthetic facial shape and proportion of the chin. METHODS: All patients undergoing cosmetic osseous genioplasty for soft tissue rejuvenation of the lower face and/or perioral region with the senior author between 2010 and 2021 were retrospectively reviewed. Complications, including infection, numbness, and prolonged ecchymosis, were recorded. RESULTS: A total of 37 patients underwent cosmetic osseous genioplasty. The average age of the cohort was 44.5 years. Twenty-six patients (70.3%) were female. Eleven patients (29.7%) underwent genioplasty alone. In addition to genioplasty, 8 patients (21.6%) underwent orthognathic surgery, 5 patients (13.5%) underwent platysmaplasty and liposuction, and 2 patients (5.4%) underwent facelift. The authors propose an algorithm to guide evaluation of the lower facial third to help determine the possible role of osseous genioplasty for facial rejuvenation based on each patient's unique facial characteristics. CONCLUSIONS: In properly selected patients, osseous genioplasty can improve lower facial projection, submandibular laxity, and perioral soft tissue support while also optimizing facial shape and proportion.

Evolution of Anomaly-Specific Techniques in Infant Ear Molding: A 10-Year Retrospective Study.

BACKGROUND: Congenital ear anomalies occur in at least one-third of the population, and less than one-third of cases self-correct. Ear molding is an alternative to surgery that spares operative morbidity and allows for significantly earlier intervention. In this retrospective study, the senior author (S.B.B.) developed a tailored approach to each specific type of ear deformity. The use of modifications to adapt standard ear molding techniques for each unique ear are described. METHODS: The authors conducted a retrospective, institutional review board-approved study of 246 patients who underwent ear molding performed by a single surgeon. The procedure reports for each case were reviewed to develop stepwise customization protocols for existing EarWell and InfantEar systems. RESULTS: This review included 385 ears in 246 patients. Patient age at presentation ranged from less than 1 week to 22 weeks. Presenting ear deformities were subclassified into mixed (37.4 percent), helical rim (28.5 percent), prominent (10.6 percent), lidding/lop (9.3 percent), Stahl ear (3.6 percent), conchal crus (3.3 percent), and cupping (2.8 percent). Two patients (0.8 percent) had cryptotia. Deformity subclass could not be obtained for 11 patients (4.5 percent). Recommended modifications to existing ear correction systems are deformity-specific: cotton-tip applicator/setting material (Stahl ear), custom dental compound mold (lidding/lop and cupping), scaphal wire (helical rim), cotton-tip applicator/protrusion excision (prominent), and custom dental compound stent (conchal crus). CONCLUSIONS: Presentation of ear anomalies is heterogenous. This 10-year experience demonstrates that the approach to ear molding should be dynamic and customized, using techniques beyond those listed in system manuals to complement each ear and to improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps.

BACKGROUND: Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population. METHODS: The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound. RESULTS: The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort. CONCLUSIONS: Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A surgeon's perspective on the uncorrected skeletal deformity. Part I: Unintended consequences on facial structures and esthetic harmony.

It is not uncommon for orthodontists to encounter patients whose malocclusion results, at least in part, from an underlying skeletal discrepancy. In many patients, these discrepancies can be fully corrected with growth modification with or without dental compensation to achieve a Class I occlusal relationship. A subset of patients with moderate skeletal deformities in whom surgery is ideally indicated but who choose to defer surgical treatment may be at risk for long-term adverse consequences on facial esthetics. As a surgeon who performs both orthognathic and facial esthetic surgery, the senior author has had the opportunity to appreciate the contributions of underlying skeletal deformities to his patients' esthetic concerns. These patients often present years after orthodontic treatment with complaints of early facial soft tissue laxity, facial disproportion, and overall dissatisfaction with facial appearance. The authors hope to illustrate to the orthodontic community the clinical picture of adult patients who present to the offices of surgeons dissatisfied with their appearance secondary to the uncorrected skeletal deformity. This paper aims to increase orthodontists' awareness of the long-term effects of uncorrected skeletal dysplasia on facial appearance. The ultimate goal is to allow the informed consent process to incorporate these esthetic consequences and to facilitate patient decision making. This article serves as Part I of a 2-part series reviewing a surgeon's approach to patients who present with facial skeletal disharmony after orthodontic treatment with dental compensation.

A surgeon's perspective on the uncorrected skeletal deformity. Part II: The role of esthetic surgery for orthognathic camouflage.

Orthognathic camouflage refers to the use of procedures other than traditional orthognathic surgery for correction of facial dysmorphology that reflects underlying skeletal discrepancy that was either not addressed on initial orthodontic evaluation or not corrected by nonsurgical treatment of the malocclusion. The authors aim to illustrate to the orthodontic community the common clinical presentation of patients who seek consultation from a surgeon citing dissatisfaction with their facial appearance secondary to orthodontic correction of the malocclusion with dental compensation but without surgical correction of the underlying skeletal discrepancy. This article summarizes the orthognathic camouflage procedures that are available as options for correction of such deformities without subjecting the patient to the potential morbidity and prolonged recovery associated with orthognathic surgery. This manuscript represents Part II of a two-part series describing a surgeon's approach to patients who present with facial skeletal disharmony after orthodontic treatment with dental compensation for malocclusions associated with an underlying skeletal discrepancy.

Social Perception of Self-Enhanced Photographs.

The use of appearance manipulating applications on our smartphones has increased in popularity. As the aim of this study is to determine the impact of self-directed appearance manipulation on perceptions of personality and examine the influence of respondent age and gender on the various personality domains. This cross-sectional cohort study included 20 subjects between the ages of 18 to 34 who had headshots taken and were provided an introduction on the use of the Facetune2 app. After 1 week of engaging in digital appearance manipulation, subjects submitted their self-determined most attractive edited photograph. Four surveys were constructed with 10 sets of photographs each. Each of these surveys were then sent to lay people via a web-based survey tool. Anonymous blinded respondents used a 7-point Likert scale to rate their perception of each patient's aggressiveness, likeability, sociability, trustworthiness, attractiveness, authenticity, and masculinity or femininity. A multivariate linear mixed effect model was applied to analyze the overall patient trait data as well as to assess the impact of rater age and gender. A total of 288 respondents (mean age range, 25-34 years [43%]; 202 [70%] female) completed a survey. Overall, digitally enhanced photographs were perceived as more attractive (0.22; 95% CI, 0.06-0.38). Analysis based on gender of the study subjects revealed increased attractiveness scores for men (0.19; 95% CI, 0.07-0.33). Females were also perceived as being more attractive (0.16; 95% CI, 0.03-0.40), but less authentic (-0.24; 95% CI, -0.36 to -0.12). Females rated enhanced photographs of men as less masculine (-0.23; 95% CI, -0.46 to -0.04). Raters aged 35 to 64 rated altered photos as less attractive (0.31; 95% CI, 0.09-0.52), authentic (0.20; 95% CI, 0.01-0.38), and gender enhancing (0.42; 95% CI, 0.24-0.61) compared with individuals aged 18 to 34. Patients and surgeons should be aware of the ways in which self-enhanced photographs may affect social perception.

Biology of COVID-19 and related viruses: Epidemiology, signs, symptoms, diagnosis, and treatment.

Coronaviruses belong to the family Coronaviridae order Nidovirales and are known causes of respiratory and intestinal disease in various mammalian and avian species. Species of coronaviruses known to infect humans are referred to as human coronaviruses (HCoVs). While traditionally, HCoVs have been a significant cause of the common cold, more recently, emergent viruses, including severe acute respiratory syndrome coronavirus (SARS-CoV-2) has caused a global pandemic. Here, we discuss coronavirus disease (COVID-19) biology, pathology, epidemiology, signs and symptoms, diagnosis, treatment, and recent clinical trials involving promising treatments.

Inferior Hypogastric Block for the Treatment of Chronic Pelvic Pain.

CONTEXT: Pelvic pain is described as pain originating from the visceral or somatic system localizing to the pelvis, the anterior abdominal wall at the level of or below the umbilicus, lumbosacral back in either men or women. EVIDENCE ACQUISITION: Narrative review. RESULTS: Chronic pelvic pain can be a complex disorder that may involve multiple systems such as urogynecological, gastrointestinal, neuromusculoskeletal, and psychosocial systems. The etiopathogenesis for chronic pain remains unknown for many patients. For achieving optimal patient management, a multimodal and individualized assessment of each patient is the best strategy. CONCLUSIONS: There are non-pharmacologic treatments as well as pharmacologic treatments. In addition to these treatment options, inferior hypogastric plexus block is a promising treatment modality.

Comprehensive Review and Update of Burning Eye Syndrome.

Keratoconjunctivitis sicca ("dry eye") is a common (14%-30% of adults over age 48) though difficult to treat condition that causes both discomfort and disability with associated dryness, pain, and visual disturbances. Etiology is not clearly understood but is likely varied, with a subset of patients suffering from chronic neuropathic pain referred to as "burning eye syndrome." This review of existing literature summarizes the clinical presentation, natural history, pathophysiology, and treatment modalities of burning eye syndrome. Chronicity of burning eye syndrome is likely secondary to increased nociception from the cornea, decrease in inhibitory signals, and nerve growth factor expression alterations. Treatment centers around symptomatic alleviation and reduction of inflammation. Conservative treatments focus on well-being and perception and include exercise, acupuncture, and cognitive behavioral therapy. Topical treatment consists of the anti-adhesion T-cell antagonist lifitegrast, corticosteroids, and cyclosporine; all have moderate efficacy and good safety. Autologous serum eye drops are a second-line topical that may promote corneal and neural healing on top of symptomatic relief. When these treatments fail, patients may trial neuromodulation with transcranial magnetic stimulation. Despite general treatment safety, more research is needed to develop novel approaches to this condition, possibly focusing more directly on the neurological component.

Supply, Demand, and Quality: A Three-Pronged Approach to Blood Product Management in Developing Countries.

While transfusion of blood and blood products is instinctively linked to the provision of emergent care, blood and blood products are also routinely used for the treatment of subacute and chronic conditions. Despite the efforts of the World Health Organization and others, developing countries are faced with a three-part problem when it comes to access to and delivery of transfusions: insufficient supply, excessive demand, and inadequate quality of available supply. Developing countries rely heavily on replacement and remunerated donors rather than voluntary nonremunerated donors due to concerns regarding donation- and transfusion-transmitted infection as well as local and cultural beliefs. While increased awareness of HIV and improved testing techniques have jointly reduced infection-related apprehensions and improved the quality of available blood and blood products, continued efforts are warranted to bolster testing for other bloodborne pathogens. Similarly, although prevalence rates of anemia are high in some areas of the world, success in adequate widespread management of these conditions has been limited. One of the keys to expanding access to high-quality blood and blood products is thus to improve medical management of conditions that would otherwise require transfusion. Through a three-pronged approach to address quantity, quality, and demand, developing countries can enable themselves to build toward self-sufficient blood management services and increased independence from the support of international organizations.

Adverse Effects of Recreational and Medical Cannabis.

Purpose of Review: This comprehensive review discusses the adverse effects known today about marijuana, for either medical or recreational use. It reviews the role of cannabis in the treatment of chronic pain, cognitive and neurological adverse effects, special cases and addiction. Recent Findings: Cannabinoids work through the endocannabinoids system and inhibit the release of GABA and glutamate in the brain, impact neuromodulation, as well as dopamine, acetylcholine and norepinephrine release. They affect reward, learning and pain. The use of cannabis is increasing nationally and world-wide for both recreational and medicinal purposes, however, there is relatively only low quality evidence to the efficacy and adverse effects of this. Cannabis and its derivatives may be used for treatment of chronic pain. They are via CB1 receptors that are thought to modulate nociceptive signals in the brain. CB2 receptors in the DRG likely affect pain integration in the afferent pathways, and peripherally CB2 also affects noradrenergic pathways influencing pain. A large proportion of users may see more than 50% of chronic pain alleviation compared with placebo. Cannabis affects cognition, most notably executive function, memory and attention, and may deteriorate the boundary between emotional and executive processing. Cannabis impairs memory in the short run, which become more significant with chronic use, and may also be accompanied by poorer effort, slower processing and impacted attention. It is generally believed that long-term use and earlier age are risk factor for neurocognitive deficits; neuroimaging studies have shown reduced hippocampal volume and density. Executive functions and memory are worse in adolescent users versus adults. Cannabis addiction is different and likely less common than other addictive substances, but up to 10% of users meet criteria for lifetime cannabis dependence. Addiction patterns may be linked to genetic and epigenetic differences. It is still unclear whether abstinence reverses patterns of addiction, and more research is required into this topic. Summary: Cannabis use has become more abundant for both medical and recreational use. It carries likely benefits in the form of analgesia, anti-emesis and improved appetite in chronic patients. The evidence reviewing adverse effects of this use are still limited, however, exiting data points to a clear link with neurocognitive deterioration, backed by loss of brain volume and density. Addiction is likely complex and variable, and no good data exists to support treatment at this point. It is becoming clear that use in earlier ages carries a higher risk for long-term deficits. As with any other drug, these risks should be considered alongside benefits prior to a decision on cannabis use.

Long-Term Outcome Assessment Between Antiseptic and Normal Saline for Negative Pressure Wound Therapy with Instillation.

Objective: To analyze long-term outcomes following inpatient treatment of infected wounds with antimicrobial or normal saline instillation during negative pressure wound therapy (NPWT). Approach: This was a single-center retrospective study analyzing the course of patients receiving 0.9% normal saline or 0.1% polyhexanide plus 0.1% betaine as instillation for wounds requiring surgery. Measured outcomes included rates of dehiscence, new wounds, re-operations, amputations, and mortality over 5 years. The article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Results: Forty-two patients received normal saline instillation and 41 the antiseptic solution. Rates of dehiscence, wound recurrence, and re-operations in the saline and antiseptic cohorts were 6.3% and 5.6%, 9.4% and 5.6%, and 14.3% and 9.8%, respectively (p > 0.05). In patients requiring further surgery, time to wound closure averaged 104 and 130 days in the saline and antiseptic cohorts, respectively (p = 0.81). Five-year amputation and mortality rates were 14.3% and 22% (p = 0.36) and 24% and 17% (p = 0.45) in the saline and antiseptic cohorts, respectively. Innovation: To compare clinical outcomes associated with two fundamentally different instillation solutions over the full wound care episode and elucidate the potential impact of these results for future applications. Conclusion: This is the first evaluation of nonsurrogate outcomes of different instillations for NPWT in infected wounds. The results indicate that normal saline instillation outcomes are comparable to those of 0.1% polyhexanide plus 0.1% betaine. The clinical success, cost benefit, and accessibility of normal saline can expand the utilization of this therapeutic approach for larger patient populations.

A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment.

PURPOSE OF REVIEW: This is a comprehensive review of the literature regarding post-surgical cutaneous nerve entrapment, epidemiology, pathophysiology, and clinical presentation. It focuses mainly on nerve entrapment leading to chronic pain and the available therapies. RECENT FINDINGS: Cutaneous nerve entrapment is not an uncommon result (up to 30% of patients) of surgery and could lead to significant, difficult to treat chronic pain. Untreated, entrapment can lead to neuropathy and damage to enervated structures and musculature, and significant morbidity and financial loss. Nerve entrapment is defined as pressure neuropathy from chronic compression. It causes changes to all layers of the nerve tissue. It is most significantly associated with hernia repair and other procedures employing a Pfannenstiel incision. The initial insult is usually incising of the nerve, followed by formation of a neuroma, incorporation of the nerve during closing, or constriction from adhesions. The three most commonly involved nerves are the iliohypogastric, ilioinguinal, and genitofemoral nerves. Cutaneous abdominal nerve entrapment could occur during thoracoabdominal surgery. The presentation of nerve entrapment usually involved post-surgical pain in the territory innervated by the trapped nerve, possibly with radiation that tracks the nerve course. Once a suspected neuropathy is identified, it can be diagnosed with relief in pain after a nerve block has been instilled. Treatment is usually started with pharmaceutical solutions, topical first and oral if those fail. Most patients require escalation to a second line of treatment and see good result with injection therapy. Those that require further escalation can choose between ablation and surgical therapies. Post-surgical nerve entrapment is not uncommon and causes serious morbidity and financial loss. It is underdiagnosed and thus undertreated. Preventing nerve entrapment is the best treatment; when it does occur, options include topical and oral analgesics, nerve blocks, ablation therapy, and repeat surgery.