Targeted Muscle Reinnervation: Factors Predisposing to Successful Pain Score Reduction.

BACKGROUND: Targeted muscle reinnervation (TMR) has demonstrated efficacy in reducing neuroma and chronic pain. In this article, we investigated postoperative outcomes in our patient cohort, with a focus on the role of nonmodifiable factors such as patient age and gender. METHODS: Patients who had extremity TMR from April 2018 to October 2022 were reviewed. Outcomes of interest included patient age, gender, cause and type of amputation, delayed versus immediate TMR, as well as postoperative improvement in pain as assessed by numerical rating score (NRS). RESULTS: A total of 40 patients underwent TMR on 47 limbs. Mean age was 46.2 ± 17.0 years. Delayed TMR (27, 57.4%) was most commonly performed, followed by immediate and delayed-immediate at 11 (23.4%) and 9 (19.1%), respectively. Amputation level was most commonly above-knee in 20 (42.6%) patients, followed by below-knee (12, 25.5%), transhumeral (8, 17.0%), transradial (6, 12.8%), and shoulder (1, 2.1%). The median time interval between amputation and TMR was 12 months. The median preoperative NRS assessing residual limb pain (RLP) for patients who underwent delayed TMR was 10. The median postoperative NRS assessing RLP for all patients was 0 (interquartile range25-75: 0-5) and significantly improved compared with preoperative NRS (P < 0.001). At the last follow-up for limbs that had delayed and delayed-immediate TMR (n = 36), 33 (91.7%) limbs had more than 50% resolution of RLP. There was a significant difference in median postoperative NRS by gender (4 in men and 0 in women) (P < 0.05). Postoperative median NRS also favored younger patients (0, <50 years compared with 4.5, >50 years) (P < 0.05). Multiple linear regression analysis showed that, of different variables analyzed, only male gender and older age were predictive of poorer postoperative outcomes. CONCLUSION: TMR showed high efficacy in our cohort, with improved short-term outcomes in women and younger patients.

Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast.

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients.

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement. METHODS: A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation. RESULTS: One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively). CONCLUSIONS: Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.

Phosphine-directed C-H borylation reactions: facile and selective access to ambiphilic phosphine boronate esters.

Ambiphilic ligands have received considerable attention over the last two decades due to their unique reactivity as organocatalysts and ligands. The iridium-catalyzed C-H borylation of phosphines is described in which the phosphine is used as a directing group to provide selective formation of arylboronate esters with unique scaffolds of ambiphilic compounds. A variety of aryl and benzylic phosphines were subjected to the reaction conditions, selectively providing stable, isolable boronate esters upon protection of the phosphine as the borane complex. After purification, the phosphine-substituted boronate esters could be deprotected and isolated in pure form.