Stable Cortical Body Maps Before and After Arm Amputation.

Neuroscientists have long debated the adult brain's capacity to reorganize itself in response to injury. A driving model for studying plasticity has been limb amputation. For decades, it was believed that amputation triggers large-scale reorganization of cortical body resources. However, these studies have relied on cross-sectional observations post-amputation, without directly tracking neural changes. Here, we longitudinally followed adult patients with planned arm amputations and measured hand and face representations, before and after amputation. By interrogating the representational structure elicited from movements of the hand (pre-amputation) and phantom hand (post-amputation), we demonstrate that hand representation is unaltered. Further, we observed no evidence for lower face (lip) reorganization into the deprived hand region. Collectively, our findings provide direct and decisive evidence that amputation does not trigger large-scale cortical reorganization.

An Unusual Appearance of Base of First Metacarpal Fracture: A Case Report.

We present the case of an unusual base of the first metacarpal fracture. The presentation and radiological images are provided to demonstrate a first metacarpal base fracture but with a concurrent appearance at first glance of a trapeziectomy mimic on plain radiographs. The CT scan however demonstrates the true nature of the injury - a comminuted fracture with carpometacarpal subluxation. The radiological and clinical findings presented a diagnostic and therapeutic dilemma. We elected to not intervene surgically with a good resulting clinical outcome, reminding us of the need to treat the patient and not their radiographic images.

The JAK inhibitor baricitinib inhibits oncostatin M induction of proinflammatory mediators in ex-vivo synovial derived cells.

OBJECTIVES: To investigate the ex vivo effect of the JAK1/2 inhibitor baricitinib on expression of pro-inflammatory mediators in rheumatoid arthritis (RA) fibroblast like synoviocytes (FLS) stimulated with TNFα, IL-1ß and oncostatin M (OSM), and in RA synovial membrane cells (SMCs). METHODS: RA and osteoarthritis (OA) SMCs, were isolated from arthroplasty specimens of RA (n=8) and OA (n=8) patients, respectively, using enzymatic digestion followed by cell propagation to obtain RA (n=5) and OA (n=3) FLS. Normal FLS and normal human foreskin fibroblasts (HSF) were purchased from commercial sources. Fibroblasts were stimulated with cytokines with or without baricitinib. RA SMCs were cultured in the presence of baricitinib without stimulation. JAK/STAT activation and levels of mRNA and proteins of the various inflammatory cytokines (IL-6, IL-8, MCP-1, RANTES and IP-10) were determined by qPCR, ELISA and MSD. RESULTS: Baricitinib inhibited OSM-induced JAK signalling in RA synovial fibroblasts and effectively suppressed subsequent expression of the proinflammatory mediators IL-6, MCP-1 and IP-10. However, baricitinib was not effective in altering levels of spontaneously released TNFα, IL-6 and IL-8 in RA SMC. Although both TNFα and IL-1ß signal independently of the JAK/STAT pathway, in HSF, but not in RA FLS, baricitinib significantly inhibited TNFα- and IL-1ß-induced MCP-1 and IP-10 protein levels in a dose dependent manner. Furthermore, baricitinib did not inhibit TNFα- and IL-1ß-induced expression of IL-6, IL-8 and MCP-1 in RA FLS. CONCLUSIONS: These findings are consistent with known signalling pathways employed by OSM, TNFα and IL-1ß, but our data suggest that in HSF, baricitinib may have anti-inflammatory effects via downstream modulation of cytokines and chemokines produced in response to TNFα or IL-1ß.

Earfold™: A combined approach with conchal bowl reduction.

BACKGROUND: Prominent ear deformity is common amongst the human population and is partly due to underdevelopment of the antihelical fold, a prominent conchal bowl, or both. Recently, the senior author described a minimally invasive technique for changing the shape of the antihelical fold using the Earfold™ implant (Allergan plc, Dublin, Ireland). However, there is still a paucity of data regarding outcomes from combing this approach with surgical techniques to correct conchal bowl hypertrophy. OBJECTIVES AND METHODS: Questionnaire-based study evaluating outcomes in consecutive patients undergoing treatment with Earfold™ and conchal bowl reduction. Patient reported outcome measures were assessed with a validated questionnaire. Data on complications were obtained from the patient's case notes and free-text sections of the questionnaire. RESULTS: Completed questionnaires were received from 8 patients out of a total of 18 who underwent the combination treatment (44% response rate). Statistically significant differences were noted in nearly all questions (18/19) relating to changes in ear appearance as a result of the surgery, with all patients being satisfied following the combined procedure. Improvements in subjective outcomes were compared to previous studies evaluating treatment with Earfold™. CONCLUSIONS: The Earfold™ implant can be combined safely with other otoplasty techniques to achieve a good outcome in a carefully selected patient population.

Earfold: A New Technique for Correction of the Shape of the Antihelix.

An absent or poorly defined antihelix often plays a central role in the perception of the prominent ear. A wide variety of otoplasty techniques have been described over the last 50 years that aim to reshape, create, or enhance the definition of the antihelix, which can, in turn, help to reduce the prominence of an ear. In addition to conventional suture and cartilage-scoring techniques, a permanent implantable clip system (Earfold® ) has recently become available that is placed using a minimally invasive approach performed under local anesthesia. In this review, we summarize conventional otoplasty techniques to correct the antihelix and compare these with the Earfold implantable clip system. Laryngoscope, 128:2282-2290, 2018.

Earfold Implantable Clip System for Correction of Prominent Ears: Analysis of Safety in 403 Patients.

BACKGROUND: The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. METHODS: This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. RESULTS: Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7-70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1-34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. CONCLUSIONS: This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.

Defining Normal Parameters for the Male Nipple-Areola Complex: A Prospective Observational Study and Recommendations for Placement on the Chest Wall.

BACKGROUND: The nipple-areola complex (NAC) is important aesthetically and functionally for both sexes. Methods for positioning the NAC in males are less well established in the literature compared to females but are just as important. OBJECTIVES: This study aims to determine the normal parameters for the male NAC, to review literature, and to present a reliable method for preoperative placement. METHODS: Normal male patients, with no prior chest wall conditions, were prospectively recruited to participate. General demographics and chest wall dimensions were recorded-sternal notch to nipple (SNND), internipple (IND), anterior axillary folds distances (AFD), NAC, and chest circumference were measured. Comparisons were made using t test and ANOVA. RESULTS: One hundred and fifty-eight patients were recruited (age range, 18-90 years); mostly (86.7%) with normal or overweight BMI. The IND averaged 249.4 mm, the SNND averaged 204.2 mm, and the AFD averaged 383.8 mm. Areola diameter averaged 26.6 mm and for the nipple, 6.9 mm. The IND:AFD ratio was 0.65. There was no statistical difference in the IND:AFD ratio, SNND, or NAC parameters comparing different ethnic groups. The SNND increased with greater BMI (P ≤ 0.001). Using these data, we suggest ideal NAC dimensions and devised a simple method for positioning of the NAC on the male chest wall. CONCLUSIONS: This is the largest study, with the widest range in age and BMI, to date on this topic. Although fewer men than women undergo surgery to the breast, there is a growing awareness for enhancing the appearance of the male chest wall.

Treatment of Prominent Ears with an Implantable Clip System: A Pilot Study.

BACKGROUND: The earFold™ implantable clip system is a new treatment for prominent ears using an implant made from nickel-titanium alloy, forged into a predetermined shape. The implant is fixed to the cartilage then released, causing the cartilage to fold back. OBJECTIVES: The study aimed to test the safety and behaviour of the implant in vivo. METHODS: This was a Phase 1, prospective, nonrandomised study. Thirty-nine patients were recruited, from 7 to 57 years of age (22 adults and 17 children). Thirty-seven patients were followed up for a minimum of 18 months. A total of 131 implants was used to treat 75 ears. All treatments were performed under local anaesthetic. RESULTS: Eighteen patients asked for their implants to be left in place permanently. Twenty-one patients agreed to have their implants removed at 6, 12, or 18 months after insertion. Complications affected 8 patients and included extrusion, infection, hypertrophic scarring, and Spock-ear formation. No new complications have arisen in any of the patients since the conclusion of the study, up to a maximum of 47 months. Patients were overwhelmingly satisfied with the outcome of treatment. CONCLUSIONS: earFold can be used as a permanent implant to correct prominence of the human ear. It is best suited for treating prominent ears with a poorly formed or absent antihelical fold. The procedure is quick and predictable with a complication rate comparable to suture-based otoplasty techniques.

Use of ITAP implants for prosthetic reconstruction of extra-oral craniofacial defects.

We report the outcomes of a single-stage, surface-mounted implant used as a bone-anchor for prosthetic reconstruction of complex facial defects. The implant used differs from other designs of osseointegrated bone-anchor because it was designed to be implanted in one-stage with the added intention of integrating with the adjacent soft-tissue. Our aim was to extend the principles underlying the intraosseous transcutaneous amputation prosthesis (ITAP) into the design of infection-free implants suitable for direct skeletal attachment of a prosthesis to the craniofacial skeleton. The implants were manufactured incorporating a porous flange structure coated with hydroxyapatite to encourage soft-tissue integration. These were inserted into the cranial facial skeleton at a number of different sites in 6 adult patients. A total of 16 implants were inserted using a one-stage procedure and implants were followed up for periods of 18 months - 7 years. One implant loosened at 3 months. This implant experienced multiple episodes of infection and was replaced with another ITAP implant 4 years later. The replacement is now stable and has never been infected at 18 months after insertion. One other patient experienced a few minor episodes of superficial infection (not requiring antibiotics) in the first year but no episodes thereafter. One patient died during follow-up (death unrelated to implant surgery). Patients were asked for their personal opinions using a structured questionnaire. All the patients were either very satisfied, or satisfied with their ITAP implants. Two patients reported problems with skin irritation under their prosthesis. All would be happy to undergo this type of surgery again. We conclude that a single-stage, surface-mounted implant designed to incorporate the principles of ITAP can be used to produce an effective bone-anchor for an external prosthesis in the reconstruction of complex craniofacial defects.

Osseocutaneous integration of an intraosseous transcutaneous amputation prosthesis implant used for reconstruction of a transhumeral amputee: case report.

Exoprosthetic replacement with an artificial limb is the main option for reconstruction after traumatic amputation of an upper limb. Direct skeletal attachment using an osseointegrated implant improves the ease of fixation of the exoprosthesis to the amputation stump. We now report the use of an intraosseous transcutaneous amputation prosthesis that is designed to achieve osseocutaneous integration. Osseocutaneous integration differs from osseointegration because the aim is to create a stable interface among the implant, the bone, and the soft tissues. This reduces the risk of soft tissue infection and troublesome discharge, which are problems encountered with current osseointegrated implants that focus largely on the bone-implant interface. We describe our experience with an intraosseous transcutaneous amputation prosthesis in a case of transhumeral amputation with 2 years of follow-up.

Patient satisfaction and aesthetic outcomes after ear reconstruction with a Branemark-type, bone-anchored, ear prosthesis: a 16 year review.

INTRODUCTION: Reconstruction of the human ear with a bone-anchored prosthesis is a widely accepted alternative when autologous reconstruction is technically impossible or declined by the individual. However, there are relatively few data in the literature documenting patient satisfaction with this form of reconstruction. METHODS: This study examines different aspects of patient satisfaction using an eighteen-point postal questionnaire to measure patient outcomes against a Likert rating scale. The questionnaire was sent to 33 patients who completed prosthetic ear reconstruction over a 16 year period at a specialist plastic surgery unit in the United Kingdom. Medical case notes for these cases were also reviewed. Twenty completed questionnaires were returned. RESULTS: The response rate was 61%. The majority of patients were satisfied with the aesthetics, ease of handling and comfort of the bone-anchored implant and prosthesis. However, the majority of patients was only moderately satisfied or was dissatisfied with this method of reconstruction. Specifically, 15 of the respondents reported skin problems around the abutments of the bone-anchored implant with 10 patients reporting ongoing skin complications. Granulation tissue was the most common skin problem (12 cases) followed by local infection (10 cases). Interestingly, despite the chronic skin problems, most patients indicated that they would undergo the same procedure again or would recommend it to others. DISCUSSION: Our survey shows that patients fitted with a Branemark-type bone-anchored implant for ear reconstruction are pleased with the aesthetic appearance but experience multiple, chronic, skin complications and other implant related problems. These affect their satisfaction with this method of reconstruction. Our findings may have significant implications for patients and surgeons considering this form of reconstruction and for the institutions making decisions about funding this treatment.

Quilting of full thickness grafts in the hand.

A skin graft is the simplest way to reconstruct an area of skin loss. To improve the chance of successful take, shearing forces and haematoma formation between the bed and the graft must be reduced. To achieve this, many surgeons use a tie-over dressing to secure the graft. However, 'quilting' the graft to the wound bed is an alternative method for securing grafts which may be superior to tie-over dressings. The purpose of this study was to compare the outcome of securing a full thickness graft by tie-over dressing versus quilting in the hand. To do this, we performed a retrospective review of graft-take in a consecutive series of 40 patients undergoing dermofasciectomy for Dupuytren's disease over a five year period. Our results demonstrate no significant difference in graft-take comparing grafts secured with a tie-over dressing or by quilting. Importantly, there were no cases of injury to the tendons or neurovascular structures in those cases where the graft was secured by quilting. Our technique for securing the graft by quilting is less time-consuming compared with a tie-over dressing. Therefore, we no longer use tie-over dressings to secure full-thickness grafts in the hand.

The tuberous breast revisited.

BACKGROUND: The tuberous breast presents a problem for which many surgical solutions have been described. Current teaching describes how the tuberous breast deformity is the result of skin shortage as well as herniation of breast tissue through the nipple-areola complex. However, through careful clinical observation we now believe that the only abnormality present is herniation of breast tissue through the nipple-areola complex. METHODS: Using this principle, we have refined a one-stage surgical procedure that can be used to correct any type of tuberous breast deformity. Since 2001 we have performed our technique on a series of 13 tuberous breasts of widely varying appearances in eight patients (age 17-24 years) with a follow up varying between 3 and 56 months. Our new understanding of the tuberous breast deformity has also made it possible to develop an objective, reproducible method for defining the tuberous breast based on the degree of areola herniation. RESULTS: All patients reported high levels of satisfaction with the procedure. Assessment of the results by an independent panel of attending surgeons showed all results to be good/excellent. Moreover, the results have improved with time and no revisions have been needed. Our method of defining the tuberous breast (based on the ratio of areola herniation:areola diameter) enabled us to identify a cut-off to decide (objectively) when a breast was tuberous. This allowed us to anticipate when an areola reduction/tightening procedure would be necessary to avoid a 'double-bubble' deformity. CONCLUSION: We propose a one-stage surgical procedure which is applicable to all degrees of tuberous breast deformity. The results appear to confirm our theory that the only abnormality present in the tuberous breast is herniation of breast tissue through the nipple-areola complex. In patients with small breasts and a tuberous deformity, correction of the herniation changes the tuberous breast into a simple hypoplastic breast. The volume deficit can then be corrected by augmentation (if desired by the patient). In patients with sufficient breast volume, correction of the herniation alone will correct the deformity.