Novel Method of Dual-innervated Free Gracilis Muscle Transfer for Facial Reanimation: A Case Series.

Background: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG. Methods: Eight patients received free gracilis muscle transfer using the new dual innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to its coaptation to the obturator nerve. Results: All patients recovered smile function with and without teeth clenching around the same time period. Smiles without teeth clenching appeared later in two of eight patients and earlier in one of eight patients, being noted at an average of 8.25 months of follow-up versus 7.6 months. The estimate of true attainment is limited by the spacing of follow-up dates. Average follow-up time was 36.07 months (range: 10-71.5). FACE-Gram software smile analysis with and without biting demonstrated similar excursion on average (7.64 mm versus 8.6 mm respectively, P = 0.93), both of which are significantly improved from preoperation. Conclusion: This novel method of a dual-innervated free gracilis muscle transfer offers a viable technique that achieves a symmetric, strong, and emotional smile.

Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion.

Aims: The benefit of MRI in the preoperative assessment of scaphoid proximal fragment vascularity remains controversial. The purpose of this study is to compare preoperative MRI findings to intraoperative bleeding of the proximal scaphoid. Methods: A retrospective review of 102 patients who underwent surgery for scaphoid nonunion between January 2000 and December 2020 at a single institution were identified. Inclusion criteria were: isolated scaphoid nonunion; preoperative MRI assessing the proximal fragment vascularity; and operative details of the vascularity of the proximal fragment with the tourniquet deflated. MRI results and intraoperative findings were dichotomized as either 'yes' or 'no' for the presence of vascularity. A four-fold contingency table was used to analyze the utility of preoperative MRI with 95% confidence intervals. Relative risk was calculated for subgroups to analyze the association between variables and MRI accuracy. Results: Preoperative MRI identified 55 proximal scaphoid fragments with ischaemia and 47 with vascularized proximal fragments. After the proximal fragment was prepared, the tourniquet was deflated and assessed for bleeding; 63 proximal fragments had no bleeding and 39 demonstrated bleeding. MRI was not reliable or accurate in the assessment of proximal fragment vascularity when compared with intraoperative assessment of bleeding. No patient or MRI factors were identified to have a statistical impact on MRI accuracy. Conclusion: Current preoperative MRI protocols and diagnostic criteria do not provide a high degree of correlation with observed intraoperative assessment of proximal fragment bleeding. While preoperative MRI may assist in surgical planning, intraoperative assessment remains the best means for assessing proximal fragment vascularity in scaphoid nonunion. Future efforts should focus on the development of objective measures of osseous blood flow that may be performed intraoperatively.

Outcomes Following Surgical Treatment of Hamate Arthrosis Lunotriquetral Ligament Injuries.

BACKGROUND: An institutional review board-approved study of the functional outcomes of patients after surgical treatment of hamate arthrosis lunotriquetral ligament tear (HALT) lesions was conducted. METHODS: In all, 21 wrists in 19 patients underwent arthroscopic, open, or combined treatment of HALT lesions. Seven patients underwent isolated hamate debridement and 14 had concomitant procedures to address lunotriquetral pathology. Nineteen wrists underwent procedures to address additional pathology, including triangular fibrocartilage complex, ulnotriquetral ligament split, and scapholunate ligament injuries. RESULTS: Mayo wrist scores increased from 54 to 71. Sixteen patients had no or mild pain postoperatively, compared with none preoperatively. When stratified by lunotriquetral interosseous ligament management, 75% of the limited treatment group (none or debridement) and 78% of the additional treatment group reported improved pain. Three patients underwent additional surgeries for persistent pain. CONCLUSION: Resection of the proximal pole of the hamate can improve pain and function for patients with ulnar-sided wrist pain secondary to a HALT lesion. Concomitant wrist pathologies should be considered when determining treatment plans.

Validating Clinical Distal Radioulnar Joint Examination With Radiographic Parameters.

BACKGROUND: The purpose of this study was to quantify the in vivo displacement of bilateral distal radioulnar joints (DRUJs) in resisted pronosupination. We hypothesize that this will demonstrate no appreciable difference between the left and right DRUJ, thus validating the concept of using the uninjured wrist as a control for physical examination as well as dynamic imaging studies. METHODS: Thirty-two participants without a history of wrist pathology underwent a dynamic computed tomography (CT) protocol evaluating bilateral forearm rotation in neutral forearm rotation, 60° pronation, and 60° supination, including maximal isometric muscle loading. The DRUJ alignment, specifically the absolute degree and direction of subluxation of the ulna relative to the sigmoid notch, was then assessed using a modification of the radioulnar line method. RESULTS: There was no significant difference in the mean displacement when comparing the right and left sides in neutral, pronation, or supination. The mean displacement was also compared between male and female patients, and there was no statistically significant difference in absolute displacement in neutral (male 0.99 mm vs female 1.38 mm) or supination (male -0.57 mm vs female -0.23 mm). However, the difference in pronation was statistically significant (male 2.69 mm vs female 3.26 mm). Of the 192 sequences, the measurements of displacement of the authors were within 1 mm 86% of the time (166 of 192). CONCLUSIONS: Dynamic CT of bilateral DRUJs in resisted pronation, supination, and neutral demonstrated symmetry between the right and left DRUJ, supporting the concept of using the contralateral side as a control to identify instability in an injured wrist.

Posttraumatic Glomus Tumor of the Digital Nerve with Atypical Presentation: A Case Report.

CASE: A 53-year-old man sustained an injury to his left index finger and underwent presumably traumatic neuroma excision from the radial digital nerve 2 years ago. He presented with a painful mass distal to the prior site of neuroma excision with distinctly different symptoms from those that led to his index surgery. Thus, he underwent excisional biopsy of the mass which was adherent to his radial digital nerve consistent with a benign glomus tumor on histologic examination. CONCLUSION: Digital nerve glomus tumors are rare. In most of the cases, some portion of the digital nerve requires excision but decreased pain can be expected.

The Plastic Surgery In-service Training Examination: An In-depth Reference Analysis.

The goal of this study was to characterize the references provided as supporting evidence of the Plastic Surgery In-service Training Examination (PSITE) syllabi, including those on the novel "core surgical principles" section. METHODS: We analyzed the references from five consecutive PSITE Examination syllabi (2016-2020). We collected the following information from each question: question section, total number of references, and source of publication of each reference. RESULTS: We analyzed 1250 questions and 3436 references. Plastic and Reconstruction Surgery was overall the most frequently referenced journal followed by Journal of Hand Surgery (American Volume) and Annals of Plastic Surgery. The most commonly referenced textbooks were Plastic Surgery (by Neligan), Green's Operative Hand Surgery, and Grabb and Smith's Plastic Surgery. Regarding the "core surgical principles" section, Plastic and Reconstruction Surgery remained the most frequently cited journal, followed by the Journal of the American Medical Association, New England Journal of Medicine, Annals, and Aesthetic Surgery Journal. "Core surgical principles" contained the largest number of unique journals (n = 209) among all test sections. Within the "core" section, Statistics in Medicine was the most frequently referenced textbook followed by Grabb and Smith's Plastic Surgery. CONCLUSIONS: The main plastic surgery texts and literature were used to support approximately half of the answers within the "core surgical principles" section. The references within this section originated from the largest number of different journals, thus highlighting the breadth and variety of this content and the challenges in preparing for this section.

The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck.

BACKGROUND: Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction. METHODS: A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded. RESULTS: Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months. CONCLUSIONS: The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.

The Evolving Trends in the Impact Factor of Plastic Surgery Journals: A 22-Year Analysis.

BACKGROUND: The journal impact factor (IF) is one of the most widely adopted metrics to assess journal value. We aimed to investigate the trends in the IF and ranking of plastic surgery journals (PSJs) over a 22-year period. METHODS: The Journal Citation Report 2018 was used to identify all journals within the field of plastic surgery from 1997 to 2018. We analyzed the IF of PSJs and that of the category surgery. RESULTS: A total of 34 PSJs were identified. The mean IF increased from 0.584 (median, 0.533) in 1997 to 1.58 (median, 1.399) in 2018 (P < 0.0001). Over the same time, the median IF of the journals in the category surgery increased from 0.914 to 1.883. The mean journal IF percentile of PSJs within surgery remained fairly stable (P = 0.999). A strong positive correlation was identified between the IF of PSJs and both the 5-year IF (r = 0.943, P < 0.0001) and the immediacy index (r = 0.736, P < 0.0001). The percentage of self-citations across the study period was fairly stable at a mean of 19.2%. A weak positive correlation was found between the IF and the percentage of self-citations (r = 0.171, P < 0.0001). CONCLUSIONS: The mean journal IF in PSJs has been trending upward over the last 22 years. Ranking of PSJs IF within the category surgery has remained unchanged. The self-citation rate has been fairly stable and correlated weakly with the IF. A strong positive correlation exists between the IF and both the immediacy index and the 5-year IF.

Breast Reconstruction in the Setting of Stage 4 Breast Cancer: Is It Worthwhile?

BACKGROUND: The role of reconstruction after primary tumor surgery for metastatic breast cancer remains controversial. This report describes the outcomes for patients undergoing mastectomy with and without reconstruction in the setting of de novo stage 4 breast cancer. METHODS: Using a prospectively maintained institutional breast surgery database, this study identified all patients who presented with de novo stage 4 breast cancer from January 2008 to December 2018. Patients were included if they had undergone mastectomy with or without reconstruction. Patient, surgical characteristics, and survival outcomes were abstracted and analyzed. RESULTS: The study identified 29 patients: 8 patients (28%) who underwent reconstruction (R) and 21 patients (72%) who did not (NR). Complete clinical response to induction systemic therapy was more frequent among patients in the R group than among those in the NR group for the primary disease (50% in R, 5% in NR), and to a lesser degree for distant disease (63% in R, 39% in NR). No difference in complication rates between the two groups was identified [n = 1 (13%) in R; n = 2 (10%) in NR; p = 1.0]. Overall survival from surgery was longer in the R group (100% at 2 and 5 years) than in the NR group [85%; 95% confidence interval (CI), 68-100% at 2 years vs 50%; 95% CI 27-91% at 5 years] (p = 0.046). CONCLUSION: Breast reconstruction after mastectomy may be reasonable to consider for appropriately selected patients with de novo stage 4 breast cancer who have excellent responses to systemic therapy and anticipated durable survival.

Altmetrics in Plastic Surgery Journals: Does It Correlate With Citation Count?

BACKGROUND: Altmetrics (alternative metrics) have become one of the most commonly utilized metrics to track the impact of research articles across electronic and social media platforms. OBJECTIVES: The goal of this study was to identify whether the Altmetric Attention Score (AAS) is a good proxy for citation counts and whether it can be employed as an accurate measure to complement the current gold standard. METHODS: The authors conducted a citation analysis of all articles published in 6 plastic surgery journals during the 2016 calendar year. Citation counts and AAS were abstracted and analyzed. RESULTS: A total of 1420 articles were identified. The mean AAS was 11 and the median AAS was 1. The journal with the highest mean AAS was Aesthetic Surgery Journal (31), followed by Plastic and Reconstructive Surgery (19). A weak positive correlation was identified (r = 0.33, P < .0001) between AAS and citations. Articles in the top 1% in terms of citation counts showed strong positive correlation between AAS and citation counts (r = 0.64, P = .01). On the contrary, articles in the top 1% of AAS had no significant correlation with citation counts (r = -0.31, P = .29). CONCLUSIONS: Overall correlation between citations and AAS was weak, and therefor AAS may not be an accurate early predictor of future citations. The 2 metrics seem to measure different aspects of the impact of scholarly work and should be utilized in tandem for determining the reach of a scientific article.

Dual innervation of free gracilis muscle for facial reanimation: What we know so far.

BACKGROUND: In the last decade, some institutions have begun combining the CFNG and masseteric nerve to provide dual innervation to the gracilis muscle for dynamic facial reanimation in facial paralysis patients. We reviewed the various ways that these two nerves have been coapted to provide dual innervation, and summarized the functional outcome for these methods. METHODS: A search of the Ovid EMBASE, MEDLINE, Cochrane, and Scopus databases was performed from 1946 to May 2019 for dual innervation of gracilis muscle using CFNG plus masseteric nerve for facial reanimation. RESULTS: A total of 184 articles were identified in the initial search, of which seven met our inclusion criteria. Three additional abstracts with 43 patients were identified but the level of details was not sufficient to include the results in the analysis. A total of 57 patients were reviewed (mean age of 42.1 years (6-79 years)). The majority of dual innervation procedures were performed using the ipsilateral masseteric nerve sutured end-to-end to the obturator nerve, and an additional CFNG connected end-to-side to the obturator nerve. In the 26 patients with Terzis scores available, there were no differences between masseteric nerve coapted end-to-end and CFNG as end-to-side to the obturator, or the reverse coaptation. All but two patients achieved function of the gracilis activated by the masseteric nerve within 2-5 months. CONCLUSIONS: This review shows that dual innervation of the gracilis is safe; and in some cases, does appear to provide early onset gracilis activation as well as an eventual spontaneous smile.

Is Rural Plastic Surgery Feasible and Important?: A Survey and Review of the Literature.

BACKGROUND: There is little written about the scope of rural plastic surgery within the United States. Approximately 25 million people do not have immediate access to a plastic surgeon. Most areas are designated as rural, and this lack of specialty care can result in suboptimal care. Physicians are more likely to move to a rural area if they have prior life experience with rural areas, but exposure to rural plastic surgery in residency training is scarce. We attempted to examine the practice characteristics of rural plastic surgeons within the United States to (a) to better define the average rural plastic surgery practice and (b) to highlight the broad scope of practice of the rural plastic surgeon to educate both hospital administrators and our physician colleagues of the impact and benefit a plastic surgeon can have on a health system. METHODS: A survey was e-mailed to surgeons identified as rural plastic surgeons who practiced in communities with fewer than 50,000 people not located in a metropolitan area. Thirty-four surgeons were identified and 12 responded to the survey. RESULTS: Respondents on average were 56 years old and had practiced for 14.3 years. At the time of the survey, 33% practiced in a hospital-employed group practice, and 33% operated in a hospital that is part of a health system. Seventy-five percent did not complete fellowship training, but 67% believed that fellowship training would be beneficial to someone interested in rural plastic surgery. Seventy-five percent recommended hand surgery as the most beneficial fellowship. Eighty-three percent had prior experiences with rural surgery before starting their practice. Average case volume ranged from 150 to more than 1000 cases per year and spanned the spectrum of plastic surgery. Potential barriers to practicing rural plastic surgery included call responsibility and facility limitations. CONCLUSIONS: A career in rural plastic surgery offers great variety encompassing the spectrum of plastic surgery. Most agreed that hand fellowship would be the most beneficial fellowship. Most had prior experience with rural surgery before seeking a career in rural plastic surgery, highlighting the importance of increasing awareness of these opportunities.

Direct muscle neurotization with long acellular nerve allograft: A case report.

Nerve repair and nerve transfer are the optimal approaches to restore function to denervated muscle. When the distal-most portion of the nerve entering the muscle is compromised, these are not possible and direct muscle neurotization (DMN) is considered. We describe the first reported case of DMN with acellular nerve allograft. The patient is a 25 year old male who sustained a blast injury to the patient's proximal leg with segmental injury to the deep peroneal nerve resulting in complete foot drop with 0/5 dorsiflexion and toe extension. Given complete obliteration of the distal nerve, we performed direct neurotization of the tibialis anterior muscle with a 7 cm acellular nerve allograft coapted to the proximal stump of the deep peroneal nerve. At 3 years after surgery, the patient regained 5/5 strength with dorsiflexion and toe extension and normal gait. This case supports the use of acellular nerve allografts to restore function to denervated muscle when the distal nerve stump is not available for nerve repair or transfer and there is a desire to avoid the morbidity of autologous nerve graft harvest.

Citation Skew in Plastic Surgery Journals: Does the Journal Impact Factor Predict Individual Article Citation Rate?

BACKGROUND: Citation skew refers to the unequal distribution of citations to articles published in a particular journal. OBJECTIVES: We aimed to assess whether citation skew exists within plastic surgery journals and to determine whether the journal impact factor (JIF) is an accurate indicator of the citation rates of individual articles. METHODS: We used Journal Citation Reports to identify all journals within the field of plastic and reconstructive surgery. The number of citations in 2018 for all individual articles published in 2016 and 2017 was abstracted. RESULTS: Thirty-three plastic surgery journals were identified, publishing 9823 articles. The citation distribution showed right skew, with the majority of articles having either 0 or 1 citation (40% and 25%, respectively). A total of 3374 (34%) articles achieved citation rates similar to or higher than their journal's IF, whereas 66% of articles failed to achieve a citation rate equal to the JIF. Review articles achieved higher citation rates (median, 2) than original articles (median, 1) (P < 0.0001). Overall, 50% of articles contributed to 93.7% of citations and 12.6% of articles contributed to 50% of citations. A weak positive correlation was found between the number of citations and the JIF (r = 0.327, P < 0.0001). CONCLUSIONS: Citation skew exists within plastic surgery journals as in other fields of biomedical science. Most articles did not achieve citation rates equal to the JIF with a small percentage of articles having a disproportionate influence on citations and the JIF. Therefore, the JIF should not be used to assess the quality and impact of individual scientific work.

Deformation of cranioplasty titanium mesh in a paediatric patient following head trauma.

Decompressive craniectomy is a life-saving procedure performed to treat intracranial hypertension caused by a variety of conditions. Subsequent cranioplasty reconstruction is needed for brain protection. Different alloplastic materials with different advantages and disadvantages are available for cranial reconstruction. We present the first case of a deformed titanium cranioplasty mesh in a paediatric patient following head trauma. Children who have undergone cranioplasty reconstruction should be counselled to wear a protective helmet when involved in contact sports or activities that may put their implant at risk of trauma.

Aseptic Freeze-Dried versus Sterile Wet-Packaged Human Cadaveric Acellular Dermal Matrix in Immediate Tissue Expander Breast Reconstruction: A Propensity Score Analysis.

BACKGROUND: Although multiple acellular dermal matrix sources exist, it is unclear how its processing impacts complication rates. The authors compared complications between two preparations of human cadaveric acellular dermal matrix (freeze dried and ready-to-use) in immediate tissue expander breast reconstruction to analyze the effect of processing on complications. METHODS: The authors retrospectively reviewed all alloplastic breast reconstructions with freeze-dried or ready-to-use human acellular dermal matrices between 2006 and 2016. The primary outcome measure was surgical-site occurrence defined as seroma, skin dehiscence, surgical-site infection, or reconstruction failure. The two groups were compared before and after propensity score matching. RESULTS: The authors included 988 reconstructions (freeze-dried, 53.8 percent; ready-to-use, 46.2 percent). Analysis of 384 propensity score-matched pairs demonstrated a slightly higher rate of surgical-site occurrence (21.4 percent versus 16.7 percent; p = 0.10) and surgical-site infection (9.6 percent versus 7.8 percent; p = 0.13) in the freeze-dried group than in the ready-to-use group, but the difference was not significant. However, failure was significantly higher for the freeze-dried versus ready-to-use group (7.8 percent versus 4.4 percent; p = 0.050). CONCLUSIONS: This is the largest study comparing the outcomes of alloplastic breast reconstruction using human acellular dermal matrix materials prepared by different methods. The authors demonstrated higher early complications with aseptic, freeze-dried matrix than with sterile ready-to-use matrix; reconstructive failure was the only outcome to achieve statistical significance. The authors conclude that acellular dermal matrix preparation has an independent impact on patient outcomes in their comparison of one company's product. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Protruding Ear: Cosmetic and Reconstruction.

Ear prominence is a relatively common cosmetic deformity with no associated functional deficits, but with profound psychosocial impact, especially in young patients. Protruding ears in children have propagated surgical advances that incorporate reconstructive techniques. Here we outline a systematic framework to evaluate the protruding ear and present various reconstructive surgical options for correction. Both cosmetic and reconstructive perspectives should be entertained when addressing this anatomical deformity.

Development of a Multidisciplinary Pediatric Surgery Fellowship.

With the rapidly changing landscape of medicine, physician assistants (PAs) have solidified their role as integral members of nearly every medical field. As PAs become leaders in smaller, more specialized fields, their duties encompass skills that they had not been exposed to in the broad, comprehensive, standard PA education. Consequently, participation in postgraduate PA education has rapidly expanded to keep up with the demand for additional training. Postgraduate PA education, frequently called "residencies" or "fellowships," offers additional specialized, hands-on, supervised clinical training along with continued didactic teaching on advanced topics. These programs offer distinct training advantages over on-the-job training. This article discusses the process of developing the Texas Children's Hospital Surgery Physician Assistant Fellowship Program and provides a framework for the development of similar programs around the country. Topics include the rationale for conception, curriculum development, applicant recruitment, and challenges along the way.