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.

COVID-19 Associated Micro-Anastomotic Thrombosis After Abdominal Free Tissue Transfer: A Case Report and Literature Review.

The hypercoagulable state of COVID-19 infection presents a challenge to microsurgeons. While the American Society of Anesthesiologists recommends deferring surgery for 4-10 weeks for COVID-19-infected patients, little else is known regarding how to mitigate thrombotic complications for patients undergoing free tissue transfer. Here, we present a presumed COVID-19-induced hypercoagulable state in a patient undergoing abdominally based free tissue transfer for breast reconstruction as a brief review of the literature to guide clinical decision making.

L'état d'hypercoagulabilité de l'infection par le virus de la COVID-19 représente un défi pour la micro-chirurgie. L'American Society of Anesthesiologists recommande de retarder la chirurgie de 4 à 10 semaines chez les patients infectés par la COVID, mais on sait peu de choses sur comment réduire les complications thrombotiques chez les patients subissant un transfert de tissu libre. Nous présentons ici un état d'hypercoagulabilité présumé induit par la COVID chez un patient subissant un transfert de tissu libre d'origine abdominale pour reconstruction mammaire comme brève revue des publications pour guider la prise de décision clinique.

Elective Hand Surgery and Antithrombotic Use in Veterans.

Background: Patients undergoing plastic surgery have traditionally been instructed to avoid anticoagulants and antiplatelets during the perioperative period to avoid bleeding that could lead to painful hematomas, skin necrosis, unplanned procedures, and blood transfusions. Many veterans are currently prescribed anticoagulants for prevention of life- and limb-threatening embolic and thrombotic events. In early 2015, the plastic surgery service began to instruct patients undergoing elective hand surgery to stay on their prescription anticoagulant perioperatively. The objective of this study was to determine the postoperative bleeding complication rate, if any, over a 7.5-year period in patients who did not interrupt their prescription anticoagulants. Methods: Health records at the Malcom Randall Veterans Affairs Medical Center in Gainesville, Florida, were queried for all plastic surgery cases performed from January 1, 2015, through June 30, 2022. Elective hand cases were identified based on the operation description and included carpal tunnel decompression (endo and open), cubital tunnel decompression (in situ), trigger finger release, trapeziectomy, small-joint fusion, neurectomy, elective amputations, and benign neoplasm removals. Patient history and physicals notes were reviewed for mention of a prescription anticoagulant on their medication list and for instructions to not discontinue blood thinner use. The postoperative notes were reviewed for up to 30 days to look for evidence of postoperative bleeding complications. Results: One hundred seventy-eight patients were identified for maintaining prescription blood thinners during their elective hand surgery. There was 1 major complication (0.6%) when a patient had to return to surgery for emergent control of bleeding. This was an in situ cubital tunnel release on clopidogrel and aspirin. There were 4 minor bleeding complications (2.2%) that were treated in the clinic with compression, wound care, or expedited follow-up for reassurance. Conclusions: Continuing prescription anticoagulants and antiplatelets during the perioperative period for elective hand surgery is a safe practice with an acceptably low local complication rate.

Lumbar Artery Perforator Flaps: A Systematic Review of Free Tissue Transfers and Anatomical Characteristics.

BACKGROUND: The lumbar artery perforator (LAP) flap has gained popularity as a versatile flap in reconstructive surgery; however, few studies have analyzed salient characteristics of this flap. We set out to provide a comprehensive appraisal of free tissue transfers of LAP flaps with specific attention to anatomic features and clinical outcomes. METHODS: Using preferred reporting items for systematic reviews and meta-analyses guidelines, we identified clinical, radiographic, and cadaveric studies of LAP flaps and assessed outcomes, complications, and anatomic parameters, such as pedicle length, diameter, location, and course. RESULTS: A total of 254 articles were initially reviewed, of which 18 met the final inclusion criteria. Ten studies were primarily concerned with anatomic characteristics, and most clinical studies related to breast reconstruction. The operative durations varied between 4.8 and 9.2 hours. Partial and total flap losses were estimated at 2.6% and 7.6%, respectively. Acute revision rates ranged from 16% to 24% related to hematoma, arterial thrombus, and venous thrombus. Donor-site seromas were frequently encountered in breast reconstruction with an incidence of 17% to 78%. CONCLUSIONS: The LAP flap has demonstrated favorable outcomes in various reconstructive scenarios. The caudal perforators generally offer more pedicle length, greater pedicle diameter, and septocutaneous course and may be better suited for flap design. For breast reconstruction, the LAP flap is a useful alternative to abdominal-based flaps, and special attention should be given to optimizing pedicle length using interposition grafts and methods that minimize seroma formation at the donor site.

Analgesic Efficacy of Nerve Blocks After Abdominoplasty: A Systematic Review.

BACKGROUND: A variety of regional nerve blocks have been utilized in abdominoplasty procedures, including transversus abdominis plane (TAP), intercostal, rectus sheath (RS), pararectus + ilioinguinal/iliohypogastric, quadratus lumborum, and paravertebral blocks. No consensus exists regarding the most effective nerve block modality in optimizing postprocedural comfort levels. OBJECTIVES: The purpose of this systematic review was to explore the efficacy of the various abdominal nerve blocks employed in abdominoplasty surgery and to draw attention to any modality that may be superior in regards to effectiveness and/or administration. METHODS: Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies that have employed regional nerve blocks in abdominoplasty procedures. Opioid consumption, pain scores, time to ambulation, time in the recovery room, and time to first analgesia request were extracted when available. RESULTS: A total of 191 articles were reviewed, of which 8 met inclusion criteria. The nerve blocks represented included TAP, RS, pararectus + ilioinguinal/iliohypogastric, intercostal, and quadratus lumborum. All modalities were effective in reducing opioid consumption except quadratus lumborum. CONCLUSIONS: TAP, RS, pararectus + ilioinguinal/iliohypogastric, and intercostal regional nerve blocks have been shown to optimize postoperative pain management in abdominoplasty procedures. The existing literature suggests that when studied against one another, TAP is more efficacious than RS and pararectus + ilioinguinal/iliohypogastric. When ultrasound guidance is unavailable, consideration should be given to TAP employing the direct visualization approach.

Topical ketoconazole for the treatment of androgenetic alopecia: A systematic review.

Androgenetic alopecia (AGA) is common and associated with significant psychosocial distress. Treatment options are needed for patients that do not adequately respond to first line treatments of finasteride or minoxidil. Topical ketoconazole has been proposed as a promising treatment. The goal of this systematic review was to evaluate the efficacy of topical ketoconazole in the treatment of AGA. A systematic literature search was conducted within the MEDLINE database using the key terms "ketoconazole" and "alopecia." Forty-seven papers were screened for inclusion, of which nine were assessed for eligibility. Seven articles were included in the qualitative synthesis, including two animal studies (total of 40 participants) and five human studies (total of 318 participants). Murine studies demonstrated a significant increase in mean ratio of hair regrowth to denuded area in the ketoconazole treatment groups compared to controls. Human studies reported increased hair shaft diameter following ketoconazole use. One study reported a significant increase in pilary index (percent anagen phase × diameter) following treatment. Studies also demonstrated clinical improvement of AGA based on photographic assessment and subjective evaluation. Topical ketoconazole is a promising adjunctive or alternative therapy in the treatment of AGA. Randomized controlled trials are needed.

Comparison of Saline Expanders and Air Expanders for Breast Reconstruction.

INTRODUCTION: Postmastectomy breast reconstruction with saline tissue expanders requires frequent saline injections. Air expanders contain an air canister and patient-operated remote to control expansion. The aim of this study was to evaluate the effectiveness of air expanders, inclusive of cost. METHODS: An international review board-approved retrospective review was performed of women who underwent breast tissue expansion between January 1, 2005 and February 5, 2019. Data collected included demographics, distance from clinic, mastectomy type, breast cancer treatment, expander type, expansion duration, postoperative visits, expansion visits, and postoperative complications. We compared true, unrealized, and overall costs and efficiency measured by time for expansion completion. True cost was calculated by adding expander, saline, and needle prices. Unrealized cost was calculated by multiplying number of visits for expansion by the expense of roundtrip driving. T tests and z scores determined clinical significance. RESULTS: Postoperative complication rates were not significantly different between groups. The air expansion mean true cost was US $1006.11 more than saline expansion (P < 0.001), whereas the mean unrealized cost was US $551.81 less (P = 0.008). The air expansion mean overall cost was US $461.43 more than saline expansion (P = 0.063). There was no significant difference in time to expander-to-implant exchange. CONCLUSIONS: This study demonstrates that saline and air expanders have no difference in complications or ability to complete expansion. However, there is significantly higher unrealized cost of saline expansion due to needle and saline costs and travel for more frequent doctor visits. However, saline expansion overall cost is less than air expansion, but statistically insignificant. Air expanders are effective in properly selected patients.

Dynamic Histological Events and Molecular Changes in Excisional Wound Healing of Diabetic DB/DB Mice.

BACKGROUND: Wound contraction and re-epithelialization over the entire healing process had never been histologically examined daily in diabetic mouse wounds. Correlating morphological characters with molecular changes may be essential to understand the potential mechanism of impeded diabetic wound healing. MATERIALS AND METHODS: In 99 db/db and 63 db/m mice, dorsal-paired 8 mm-diameter wounds were created. Wound contraction and re-epithelialization were histologically analyzed daily-six wounds per group each day. A novel three-dimensional collagen gel model was used to study diabetic dermal fibroblast contractility. Fibroblast-to-myofibroblasts differentiation and TGFß-SMAD signaling pathway through the diabetic db/db wound healing process were studied by immunohistochemistry. RESULTS: Db/db wounds presented delayed closure with impaired wound contraction. Re-epithelialization was not slow but showed thinner epithelial formation and irregular keratinocyte arrangement. Diabetic dermal fibroblasts had significantly lower contractile ability than nondiabetic fibroblasts. In db/db wounds, α-SMA, the marker of myofibroblasts, showed constantly low through the healing, which represented reduced fibroblast-to-myofibroblasts differentiation. Remarkably weak staining of TGFßRI and low accumulation of Smad3 in nuclei were observed. CONCLUSIONS: We demonstrated and precisely located downregulated TGFß signaling pathway in db/db wounds by showing low expression of TGFßRI and failure of Smad3 translocation from cytoplasm to nuclei, which was not reported previously. The downregulated TGFß signaling pathway may contribute to the attenuated fibroblast-to-myofibroblast differentiation. Deficient re-epithelialization and defective wound contraction contribute principally to delayed healing of diabetic db/db wounds.