Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function.

Introduction: Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma. Materials and Methods: A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure. Results: Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61). Conclusion: Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience.

BACKGROUND AND OBJECTIVE: Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction. METHODS: A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. RESULTS: Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures. CONCLUSION: Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Bilateral gluteal reconstruction with deep inferior epigastric perforator flaps and saphenofemoral arteriovenous loops.

The use of liquid silicone injections for soft tissue augmentation harbors numerous risks and is not approved by the FDA. Still, such injections are frequently performed by unlicensed providers, often in the gluteal region, and can lead to infection, soft-tissue breakdown, scarring, and disfigurement. The purpose of this case report was to demonstrate the use of immediate, abdominally based free flaps for reconstruction in a patient with bilateral total gluteal defects and limited inflow options in the setting of remote silicone injections. The patient is a 45-year-old female who developed chronically infected injected silicone in the bilateral buttocks leading to draining abscesses and soft tissue breakdown. The patient required radical debridement and excision of the bilateral buttocks to remove all foreign material. After intermediate skin grafting of the residual wounds, the patient then was deemed a candidate for bilateral free flap reconstruction of the buttocks. On exploration of the bilateral defects, both 20 cm × 10 cm in size, the gluteal vessels were non-usable, and preoperative CTA additionally had revealed no suitable posteriorly based perforators. Therefore, bilateral arteriovenous (AV) loops, measuring 30 cm in length, were then constructed utilizing the greater saphenous veins anastomosed to the femoral arteries which were then tunneled to the defect. The soft tissue defects were concurrently reconstructed with bilateral deep inferior epigastric perforator (DIEP) flaps measuring 16 cm × 12 cm. The postoperative course was complicated by small seromas in each groin requiring drain placement by interventional radiology on postoperative day 16. Otherwise, the patient's buttocks healed well, and functionally, the patient had regained the ability to sit and was satisfied with the aesthetic appearance of the reconstruction as of last follow-up at 10 months. Abdominally based free flap reconstruction with AV loops, in this case, provided for successful reconstruction of otherwise challenging soft-tissue defects with limited inflow options.

Functionally graded 3D printed plates for rib fracture fixation.

BACKGROUND: Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends. METHODS: Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined. FINDINGS: The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups. INTERPRETATION: Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas.

Using Integra for Reconstruction of Facial Defects after Mohs Micrographic Surgery.

Background: We aimed to identify how Integra bilayer wound matrix has expanded facial reconstruction options after Mohs surgery due to its reliability in both single- and dual-stage reconstruction. Methods: A retrospective review of patients undergoing Mohs surgery and alloplastic facial reconstruction with Integra between 2012 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. Results: One hundred thirty patients with a median age of 76 years were included. Basal cell carcinoma was the most common malignancy (39%). One hundred forty-two lesions were treated and reconstructed same-day with Integra. Lesions most commonly involved the nose (34%) and forehead (22%). The mean postoperative defect size was 26.9 cm2. An estimated 45.5% (n = 60) of defect sites underwent single-stage reconstruction with healing by secondary intention, whereas 54.5% (n = 72) underwent dual-stage reconstruction with skin graft. Integra success rate was 90.2%. Average time to re-epithelialization was 32.2 + 7.3 days. Average time to repigmentation was 169.5 + 14.6 days. The complication rate was 12.8% (n = 17), with 12 undergoing debridement, three needing new Integra graft, and seven needing new skin grafts. Average size for successful healing without complication was 26.6 cm2. Nineteen sites (13.2%) underwent aesthetic improvement procedures, with the majority occurring after dual-stage reconstruction (n = 13). Conclusions: Integra is a reliable outpatient reconstructive option for facial Mohs defects that can increase the threshold for autologous tissue harvesting and successfully reconstruct large defects of 26.6 cm2 on average with low complication and reoperation rates.

Poly-4-hydroxybutyrate Mesh for Ventral Hernia Repairs: A Single-Surgeon Experience.

Background: Poly-4-hydroxybutyrate (P4HB) (Phasix) biosynthetic mesh was recently introduced as an alternative to synthetic and biologic meshes for ventral hernia repair (VHR). However, outcomes data are limited. This study aims to analyze outcomes of VHR with P4HB mesh and identify predictors of postoperative outcomes. Methods: We performed a retrospective study of adults who underwent open VHR with P4HB by the senior author from 2014 to 2020 with >12 months' follow-up. Subgroup comparisons and multivariate logistic regression were performed. Results: Inclusion criteria were met by 169 patients with a median of 15 months of follow-up. Overall, 21.9% had surgical site occurrences, 17.8% required reoperation, and 4.7% had recurrences. Patients with prior VHR (47.9%) experienced similar outcomes to those without. Patients with prior mesh infection (18.3%) had higher rates of postoperative mesh infection (6.5% vs 0.7%; P = .029) but did not have higher rates of reoperation. Retrorectus repairs (45.5%) had similar outcomes to onlay repairs (54.5%). Recurrence risk was increased by hypertension (odds ratio [OR] = 13.64; P = .046), immunosuppression (OR = 42.57; P = .004), and history of prior VHR (OR = 20.20; P = .014). Conclusions: This study aimed to analyze outcomes of VHR augmented with P4HB mesh through retrospective review. VHR with P4HB mesh produces acceptable recurrence rates with favorable complication risks compared with biologic and synthetic meshes. Predictors of recurrence include a history of prior hernia repair, hypertension, and immunosuppression. A history of prior mesh infection seems to place patients at risk for developing subsequent infection but did not increase need for reoperation.

Exploring Factors Associated with Implant Removal Satisfaction in Breast Implant Illness Patients: A PRO BREAST-Q Study.

Background: Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear. Methods: A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors. Results: Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores (P = 0.015). Self-pay was predictive of increased breast satisfaction scores (P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms (P = 0.032). Psychiatric illness had no significant impact on the outcomes. Conclusions: In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

PURPOSE: Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. METHODS: This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. RESULTS: Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). CONCLUSIONS: In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

Prospective, multicenter study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (XenMatrix™ AB Surgical Graft) for hernia repair in all centers for disease control and prevention wound classes: 24-month follow-up cohort.

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR). Materials and methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m2) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months. Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline. Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life.

The Role of Dedicated Research Training in Promoting Academic Success in Plastic Surgery: Analysis of 949 Faculty Career Outcomes.

This study aimed to analyze the association between completion of research training and career success in American plastic surgery faculty to aid trainees in their decisions to perform research fellowships. Methods: A cross-sectional analysis of attending academic plastic surgeons in the United States was conducted. Outcomes were compared between faculty who completed research training (research fellowship, PhD, or MPH) and those who did not. Outcomes included promotion to full professor and/or department chair, h-index, and attainment of National Institutes of Health funding. Outcomes were analyzed using chi-squared tests, t tests, and multivariable regressions. Results: A total of 949 plastic surgery faculty members were included, and of those, 185 (19.5%) completed dedicated research training, including 13.7% (n = 130) who completed a research fellowship. Surgeons who completed dedicated research training were significantly more likely to achieve full professorship (31.4% versus 24.1%, P = 0.01), obtain National Institutes of Health funding (18.4% versus 6.5%, P < 0.001), and have a higher mean h-index (15.6 versus 11.6, P < 0.001). Dedicated research fellowships were independently predictive of achieving full professorship (OR = 2.12, P = 0.002), increased h-index (ß = 4.86, P < 0.001), and attainment of National Institutes of Health funding (OR = 5.06, P = 0.01). Completion of dedicated research training did not predict an increased likelihood of becoming department chair. Conclusion: The performance of dedicated research training was predictive of improved markers of career success in plastic surgery and should be considered beneficial in both the short and long term.

Expanding Indications of the Medial Femoral Condyle Free Flap: Systematic Review in Head and Neck Reconstruction.

The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck. Methods: A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm2. The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture. Conclusion: The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.

A Consensus Approach for Targeted Muscle Reinnervation in Amputees.

Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.

Aesthetic Considerations in Extremity Salvage and Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Have an in-depth understanding of the functional and aesthetic requirements of lower extremity reconstruction. 2. Describe the considerations for achieving an optimal aesthetic outcome in the primary reconstruction settings. 3. Describe modalities of secondary flap revision for achieving an optimal aesthetic outcome. SUMMARY: Significant advancements have been made in the management of lower extremity reconstruction since Dr. Taylor's seminal case in 1973. Improvements in our understanding of vascular anatomy and evolution of microsurgical techniques have allowed for an ever-increasing array of free tissue transfer options for lower extremity reconstruction. The resulting expertise has engendered a paradigm shift toward the reconstructive elevator approach, with increased emphasis on cosmetic results. In the primary setting, aesthetic considerations play an important role in precoverage wound preparation, flap selection, and harvest technique, with the goal of achieving excellent like-with-like reconstruction at the time of initial surgery. Flap selection should be made to best match the three-dimensional architecture of the wound, and take into account the defect thickness, flap thickness, flap composition, and pedicle length. Primary flap thinning and harvest in the superficial fascial plane has been shown to be an effective modality to address excess adiposity and improve contour. Despite these efforts, secondary procedures are often required to optimize the limb's final appearance and functional outcomes, particularly in the foot and ankle region. These include debulking, liposuction, and staged excisions. As the field of limb salvage keeps evolving, aesthetics will continue to play an important role in extremity reconstruction planning and execution.

A retrospective case series of Mohs micrographic surgery and interdisciplinary management of female genital skin cancers: Local recurrence rates and patient-reported outcomes.

BACKGROUND: Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRRs) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers. OBJECTIVE: To evaluate LRRs, PROs, and interdisciplinary care after MMS for female genital skin cancers. METHODS: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care. RESULTS: Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n = 26), basal cell cancer (n = 12), and extramammary Paget disease (n = 11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60). LIMITATIONS: Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data. CONCLUSIONS: Incorporating MMS into interdisciplinary teams may help achieve low LRRs and satisfactory function after genital skin cancer surgery.

Outcomes following Free Fibula Physeal Transfer for Pediatric Proximal Humerus Reconstruction: An International Multi-Institutional Study.

BACKGROUND: Vascularized fibula epiphyseal flap was first described in 1998 for proximal humeral reconstruction in children/infants. The authors aim to review their international, multi-institutional, long-term outcomes. METHODS: An international, multi-institutional review (2004 to 2020) was conducted of patients younger than 18 years undergoing free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. Donor- and recipient-site complications, pain, and final ambulatory status were reviewed. Growth of the transferred bone was assessed under the guidance of a pediatric musculoskeletal radiologist. RESULTS: Twenty-seven patients were included with a median age of 7 years (range, 2 to 13 years). Average follow-up was 120 ± 87.4 months. There were two flap failures (7.4%). Recipient-site complications included fracture [ n = 11 (40.7%)], avascular necrosis of the fibula head [ n = 1 (3.7%)], fibular head avulsion [ n = 1 (3.7%)], infection [ n = 1 (3.7%)], and hardware failure [ n = 1 (3.7%)]. Operative fixation was necessary in one patient with a fracture. The case of infection necessitated fibula explantation 2 years postoperatively, and ultimately, prosthetic reconstruction. Sixteen patients developed peroneal nerve palsy (59.3%): 13 of these cases resolved within 1 year (81% recovery), and three were permanent (11.1%). One patient (3.7%) complained of upper extremity pain. Longitudinal growth was confirmed in all but three cases [ n = 24 (88.9%)] at an average rate of 0.83 ± 0.25 cm/year. CONCLUSIONS: The vascularized fibula epiphysis for proximal humerus reconstruction in children preserves the potential for future growth and an articular surface for motion. Peroneal nerve palsy is common following harvest, although this is often transient. Future efforts should be geared toward reducing postoperative morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microsurgical Peritoneovenous Bypass for the Treatment of Recalcitrant Chylous Ascites.

BACKGROUND: New treatments for recalcitrant chylous ascites are needed to avoid sequelae associated with increased intraabdominal pressures, chyle loss, and diminished quality of life. An autologous microsurgical technique was developed to treat recalcitrant chylous ascites and restore normal physiology. METHODS: A retrospective case series was performed for patients with recalcitrant chylous ascites surgically treated from 2018 to 2020. The authors included all patients with recalcitrant chylous ascites refractory to current standard-of-care interventions such as diet modifications, pharmacologic therapies, and peritoneovenous mechanical shunts. All were treated with microsurgical peritoneovenous bypass with a minimum follow-up of 12 months. RESULTS: Six patients were included over a 2-year period. Surgery was aborted for two patients (33%) with intraoperative venous reflux of the deep inferior epigastric vein, negative on preoperative ultrasound. One patient had a successful reoperation using the contralateral greater saphenous vein; the other elected for a chronic indwelling drain for chyle drainage. Among the five successful procedures (83%), ascites drainage decreased from a median preoperative volume of 1 L/day to postoperative volume of 0.06 L/day. Median hospital length of stay was 7 days (range, 212 to 194 days). Three patients had one complication each, including vancomycin-resistant Enterococcus , spontaneous bacterial peritonitis, and pulmonary embolism. All complications resolved with additional interventions. Median follow-up was 13.5 months (range, 12 to 27 months). CONCLUSION: Microsurgical peritoneovenous bypass was a reliable and reproducible autologous surgery for the treatment of recalcitrant chylous ascites at a minimum follow-up of 12 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.