Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review.

PURPOSE: The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects. METHODS: A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap. RESULTS: Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%). CONCLUSIONS: Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

Composite Anterolateral Thigh and Fascia Lata Free Flap for Abdominal and Groin Reconstruction in a Pediatric Patient.

Large abdominal wall and groin defects present complex reconstructive challenges. These defects typically require free flap reconstruction to bring in healthy vascularized tissue and recreate the complex full-thickness defect. A 6-year-old previously healthy girl presented to our trauma center after sustaining a close-range shotgun injury resulting in a full-thickness defect to the inferior hemi-abdomen and groin. A composite anterolateral thigh flap with fascia lata free flap was performed to reconstruct the myofascial, skin, and subcutaneous tissue of the abdomen and groin. We present the first composite anterolateral thigh flap with fascia lata for full-thickness abdominal wall and groin reconstruction in a pediatric patient.

The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction.

BACKGROUND: Soft-tissue defects of the distal lower extremity and foot present significant challenges to the reconstructive surgeon. The reverse superficial sural artery flap (RSSAF) is a popular option for many of these difficult wounds. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. To overcome this, we have modified our operative technique, which has produced a more reliable flap. METHODS: All patients reconstructed with an RSSAF between May 2002 and September 2013 were retrospectively reviewed. In response to a high rate of venous congestion in an early group of patients, we adopted a uniform change in operative technique for a late group of patients. A key modification was an increase in pedicle width to at least 4 cm. Outcomes of interest included postoperative complications and limb salvage rate. RESULTS: Twenty-seven patients were reconstructed with an RSSAF (n = 12 for early group, n = 15 for late group). Salvage rate in the early group was 50% compared with 93% in the late group (P = 0.02). Postoperative complications (75% vs. 67%, P = 0.70) were similar between groups. Venous congestion that required leech therapy was 42% in the early group (n = 5) and 0% in the late group (P = 0.01). CONCLUSIONS: Venous congestion greatly impairs the survival of the RSSAF. A pedicle width of at least 4 cm is recommended to maintain venous drainage and preserve flap viability.

Endoscopic management of the difficult lower eyelid: a review of 300 cases.

BACKGROUND: The senior author's (H.S.B.) endoscopic brow and midface lift technique has a series of periorbital suture points. This study evaluated the efficacy of endoscopic treatment of the difficult lower eyelid and identifies the preoperative predictive patterns for additional suture placement and ancillary procedures within this population. METHODS: Patients who underwent endoscopic brow and midface lift performed by the senior author were stratified into categories of preoperative lower eyelid morphologies, including lower eyelid retraction, negative canthal tilt, negative vector orbit, exorbitism, and a deep tear trough. Intraoperative treatment and postoperative course were recorded and postoperative photographs were evaluated objectively. The data were analyzed to determine preoperative predictive patterns of endoscopic lower eyelid treatment. RESULTS: Three hundred patients who underwent an endoscopic brow and midface lift between 1999 and 2008 were included in the study, with an average follow-up of 1 year. Most patients were treated with endoscopic orbicularis oculi repositioning combined with midface elevation. Additional suture points were used in 12 percent, with preexisting scleral show being the most common indication for additional endoscopic suture placement. There were no cases of postoperative lower eyelid retraction. Skin resurfacing and volumetric filling were the most common revision procedures. CONCLUSIONS: The difficult lower eyelid can be treated effectively with endoscopic orbicularis repositioning and midface elevation. This technique preserves the innervation and continuity of the orbicularis oculi muscle, decreasing postoperative complications. Additional suture application is needed in only a minority of patients, and ancillary lower eyelid procedures can be performed safely in the same operative setting.

Neurovascular compression of the greater occipital nerve: implications for migraine headaches.

BACKGROUND: Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes. A cadaveric investigation was performed in an effort to further delineate the occipital artery-greater occipital nerve relationship. METHODS: Fifty sides of 25 fresh cadaveric posterior necks and scalps were dissected. The greater occipital nerve was identified within the subcutaneous tissue and its relationship with the occipital artery was delineated. A topographic map of the intersection of the two structures was created. RESULTS: The greater occipital nerve and occipital artery have an intimate relationship, and crossed each other in 27 hemiheads (54.0 percent). The relationship between these structures when they crossed varied from a single intersection to a helical intertwining. CONCLUSIONS: The greater occipital nerve and occipital artery have an anatomical intersection 54 percent of the time. There are two morphologic types of relationships between the structures: a single intersection point and a helical intertwining. Vascular pulsation may cause irritation of the nerve and is a possible explanation for migraine headaches that have the occipital region as a trigger point. Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation.

Capsular contracture with breast implants in the cosmetic patient: saline versus silicone--a systematic review of the literature.

BACKGROUND: Capsular contracture is one of the most common and trying complications associated with the placement of breast prostheses. The authors hypothesized that silicone implants have a higher rate of capsular contracture than saline implants when used for cosmetic, nonreconstructive breast augmentation. This was based on several previous studies and the experience of the senior author (R.J.R.). The authors objectively evaluated this hypothesis using a systematic review of the literature, specifically examining the incidence of capsular contracture with saline and silicone cosmetic breast implants. METHODS: A review of the PubMed, OVID, and Cochrane databases for prospective studies using these implants and having at least 1-year follow-up on all implants was performed. Reference articles of the articles meeting these inclusion criteria were also included. Two independent reviewers performed the same systematic review with the same a priori criteria, and discrepancies were settled by the senior author. RESULTS: The systematic review was performed in March of 2009. One thousand six hundred ninety-six articles were identified as potentially inclusive based on the search term "breast augmentation." When filtered for "saline or silicone" search terms, 583 articles were found. In the end, 16 articles met inclusion criteria. CONCLUSIONS: There is a lack of current prospective data comparing saline and silicone breast implants in the literature, thereby interfering with the ability of physicians to make data-driven recommendations to patients based on the best medical evidence. The authors were unable to accept or reject their null hypothesis definitively based on this review.

The zygomaticotemporal branch of the trigeminal nerve: Part II. Anatomical variations.

BACKGROUND: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerve's foramen and intramuscular course. METHODS: The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks. RESULTS: In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen. CONCLUSIONS: The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.

Systems of provision and delivery of hand care, and its impact on the community.

Hand injuries are important causes of impairment in the United States. They are one of the top causes for days lost from work and they impose a great economic burden on the country. In less affluent regions of the world, the impact of hand injuries on the population is even more dire, rendering the affected to life-long disability. When one considers that 85% of the world's population lives in low to middle income countries, the global deleterious effect of hand trauma becomes apparent. This paper is a review of pertinent literature available on the provision and delivery of trauma care around the world. While specific reference to hand surgery care is sparse, we will infer trauma management in these countries, synthesised from available literature, to the provision of hand surgery care. We will also examine programs around the world that are implemented at an affordable cost to the respective countries.

Abdominal aortic aneurysm.

Most abdominal aortic aneurysms (AAAs) are asymptomatic, not detectable on physical examination, and silent until discovered during radiologic testing for other reasons. Tobacco use, hypertension, a family history of AAA, and male sex are clinical risk factors for the development of an aneurysm. Ultrasound, the preferred method of screening, is cost-effective in high-risk patients. Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year. Asymptomatic patients with an AAA should be medically optimized before repair, including institution of beta blockade. Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity and is a surgical emergency requiring immediate repair. The mortality rate approaches 90 percent if rupture occurs outside the hospital. Although open surgical repair has been performed safely, an endovascular approach is used in select patients if the aortic and iliac anatomy are amenable. Two large randomized controlled trials did not find any improvement in mortality rate or morbidity with this approach compared with conventional open surgical repair.