Marinacci Communication With Recovery of the Thumb, Finger, and Wrist Flexion After a High Median Nerve Injury: A Case Report and Review of Literature.

The Marinacci communication (MC) contains fibers from the ulnar to the median nerve in the forearm in a proximal to distal fashion. This rare ulnar-to-median nerve anomalous communication has mainly been reported as an incidental finding. In the case presented here, this anatomical variation led to rapid recovery of the thumb, finger, and wrist flexion following a high above elbow complete median nerve injury. A 17-year-old female was involved in an all-terrain vehicle rollover accident and had her right elbow crushed. She presented with no motor or sensory function in the forearm and hand, with a weak monophasic radial artery signal and no palpable pulse. She underwent surgery and was treated with 12 cm interposition cable sural nerve grafting. Although recovery after a high median nerve injury is often prolonged and incomplete, the MC resulted in the recovery of sensation and motor function through muscles typically innervated by the median nerve, following a complete high median nerve injury. In the presence of anomalous recovery following median nerve injury or unusual electrophysiological findings, an MC should be considered as a cause.

Surgical Treatment of Advanced Carpometacarpal Joint Arthritis: Trapeziectomy with Hematoma Arthroplasty.

Osteoarthritis of the first carpometacarpal joint is common. When nonoperative measures fail, surgery may provide long-term pain relief. There are many surgical options in the management of carpometacarpal joint arthritis. Trapeziectomy with hematoma arthroplasty is technically simple, inexpensive, and has withstood the test of time. It is an excellent option for advanced carpometacarpal joint arthritis with multiple high-quality studies showing equivalent outcomes between this technique and ligament reconstruction tendon interposition techniques. This article reviews trapeziectomy with hematoma arthroplasty for treatment of carpometacarpal joint arthritis, including the indications for the procedure, the authors' preferred technique, and the current literature.

Supine harvest of vascularised scapular bone grafts-Anatomical study and clinical application.

BACKGROUND: We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach. METHODS: Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper. RESULTS: There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm. CONCLUSIONS: Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.

Technical Considerations and Clinical Applications of the Free Anterior Branch Split Latissimus Dorsi Flap.

BACKGROUND: The free anterior branch split latissimus dorsi flap has a reliable anatomy and advantages over the traditional latissimus dorsi flap. By preserving the posterior branch of the thoracodorsal nerve, morbidity at the donor site is reduced, preserving shoulder strength. METHODOLOGY: The purpose of this article is to review our experience with the split latissimus flap, describe our surgical technique, and finally review representative cases of reconstruction in different anatomical regions. RESULTS: From April 2017 to October 2020, 39 free split latissimus flaps were performed at a single center. Flaps were performed for coverage in the upper extremity (n = 2), lower extremity (n = 32), and head and neck (n = 5). Flap success rate was 97.4%. Mean dimensions of the flap were 17.0 × 8.3 cm, with a mean area of 145 cm2. CONCLUSIONS: The flap has a broad application and can be utilized in many different reconstructive scenarios including for coverage of defects in the extremities, trunk, and head and neck.

Safety of Coupled Arterial Anastomosis in Autologous Breast Reconstruction.

BACKGROUND: This study compares the outcomes of coupled versus hand-sewn arterial anastomosis in microvascular breast reconstruction. METHODS: Retrospective chart review of breast reconstruction free flaps performed between 2013 and 2018 was conducted. Primary end points included flap loss, intraoperative arterial anastomosis revision, and operating room takeback. The decision to couple the arterial anastomosis was based on patient's age, surgeon's preference, history of radiation, and vessel quality. All anastomoses were performed under ×3.5 loupe magnification to internal mammary or thoracodorsal vessels. RESULTS: Authors reviewed 104 free flaps; two were lost in hand-sewn group; no flaps were lost in coupled group. There was no significant difference in anastomotic revision rate between coupled and hand-sewn arterial anastomosis (p = 0.186) or return to operating room (OR) between coupled and hand-sewn flaps (p = 1.000). Reasons for takeback included venous congestion and hematoma. CONCLUSION: This study reflects that coupled arterial anastomosis in breast reconstruction may be safely performed without increased risk in anastomotic revision, takeback, or flap loss. Decision to couple should be based on surgeon skill, patient age and history, and assessment of flap and recipient site vasculature.

Function-Sparing Free Split Latissimus Dorsi Flap for Lower-Extremity Reconstruction: Five-Year Consecutive Single-Surgeon Series.

BACKGROUND: The free split latissimus dorsi flap for lower-extremity reconstruction has some advantages over the traditional latissimus dorsi flap. The flap is harvested with the patient in the supine position and is associated with minimal morbidity as the function of the remaining latissimus dorsi muscle is preserved through the posterior division of the thoracodorsal nerve. METHODS: A consecutive single-surgeon 5-year series of free split latissimus dorsi muscle flaps for lower-extremity reconstruction (n = 42) was evaluated. Donor site morbidity was evaluated through assessment of the strength of the remaining latissimus dorsi at least 1 month after surgery. Shoulder function was evaluated postoperatively using the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Shoulder Pain and Disability Index (SPADI). RESULTS: The mean age of the 42 patients was 40.7 years. The mean length and width of the flaps were 17.9 cm and 8.6 cm. The majority (71%) of the wounds were due to acute trauma. Of the 42 flap procedures performed, 95% (40) were successful. Assessment of remaining latissimus dorsi strength at least 1 month postoperatively, during 3 activities, showed a Medical Research Council (MRC) grade of 5 in all patients. The mean and median scores were 6.4 and 0 according to the DASH, 6.0/6.4 and 0/0 on the SPADI pain/disability scales, and 90.7 and 100 on the ASES. CONCLUSIONS: The free split latissimus dorsi flap is a large reliable muscle flap with negligible donor site morbidity that is particularly advantageous for lower-extremity resurfacing following trauma. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mastopexy: Current Trends in Private Practice and Academic Practice and the Impact on Resident Training.

INTRODUCTION: Training residents for cosmetic surgery is challenging. This study's goal is to identify the mastopexy spectrum, comparing private and academic practice, and determine the impact on resident training and readiness. METHODS: An institutional review board-approved retrospective analysis of the senior author's mastopexy practice was performed: 5 years private; 5 years academics consecutively. Indications for surgery, type of surgery, and complications (return to operating room, hospital readmission, prosthesis loss, nonoperative hematoma, seroma, wound dehiscence, infection) were recorded. Surveys were sent to all graduated, board-certified plastic surgeons (all in private practice) who trained in performing mastopexy with the lead surgeon in our apprenticeship model. RESULTS: A total of 246 mastopexies were reviewed (155 in private practice and 91 in academic setting). There were 7 main indications for mastopexy identified: ptosis, postpartum atrophy, nonsurgical weight loss, surgical weight loss, asymmetry, reconstruction/balancing, revision from previous augmentation. Fisher exact test was performed. Primary mastopexy alone was significantly more prevalent in private practice (P = 0.0184). Revisional mastopexy/augmentation was significantly more prevalent in academic practice (P = 0.0047). There was no statistical difference in major or minor complications between private and academic setting (P = 0.077 and P = 0.219, respectively). All graduated trainees reported being "comfortable" or "very comfortable" performing mastopexies. DISCUSSION: Primary mastopexy is more commonly performed in a private practice setting. Mastopexy, in academics, is more likely in conjunction with reconstruction/balancing. Despite lesser representation of pure cosmetic mastopexy, trainees are well prepared for mastopexy. This indicates that principles and techniques of aesthetic surgery are adequately taught.

Comparative Outcomes and Quality Analysis of Inverted-T and Pure Vertical Scar Techniques in Superomedial Pedicle Reduction Mammaplasty.

INTRODUCTION: Multiple techniques exist for reduction mammoplasty, but no singular consensus exists as to which method is the most effective in providing an aesthetically pleasing breast. We reviewed our institution's reduction mammoplasty experience over a 2-year period to evaluate aesthetic and surgical outcomes comparing superiorly based pedicles with skin excisions resulting in either an inverted T or vertical scar. METHODS: An IRB-approved retrospective review of our institution's surgical database identified patient characteristics and outcomes of all breast reductions performed over a 2-year period (n = 104). A subgroup analysis of patients with complete preoperative and postoperative photographs (n = 56) evaluated postoperative aesthetics on a scale of 1 to 5 (1, poor; 5, excellent). RESULTS: Techniques included a superomedial pedicle with an inverted T-pattern skin excision (n = 81) and pure vertical reduction (n = 23). There was no significant difference in complications between techniques. Common patient risk factors (age, body mass index [BMI], and smoking status) did not correlate with postoperative complications. In the photograph analysis subgroup, inverted T scar pattern reductions had a significantly better scar quality score (3.5 vs 3.2, P < 0.05). In analysis of all subjects, volume of tissue resected was a significant factor in determining overall aesthetic score, with resections of less than 1300 g being significantly associated with an overall aesthetic score of 4 or higher. Logistic regression demonstrated patient age younger than 40 years was a significant contributor to aesthetic score of 4 or higher (P < 0.05). DISCUSSION: We reviewed our institution's experience with 2 common breast reduction techniques. Better scarring was associated with inverted T scar pattern versus vertical pattern. Additionally, rather than pedicle type or skin excision pattern, patient age and weight of tissue resected were the most important contributors to an aesthetically optimal outcome. This study suggests that a single superlative technique does not exist. Rather, inherent patient characteristics are most important in provision of the best aesthetic outcome.

Maximizing chemoprophylaxis against venous thromboembolism in abdominoplasty patients with the use of preoperative heparin administration.

BACKGROUND: Abdominoplasty is one of the highest risk plastic surgery procedures for venous thromboembolism complications (VTE). Current recommendations for VTE prophylaxis are sequential compression devices (SCDs) in the OR and optional use of subcutaneous heparin after surgery. Subcutaneous heparin has been shown to be safe in other surgical groups. However, the large raw surface areas and dissection involved in abdominoplasty has been a relative contraindication for preoperative chemoprophylaxis. However, the period while the patient is under general anesthesia and immediately following the procedure is likely the highest risk time period for VTEs. The purpose of this study is to determine if preoperative chemoprophylaxis is safe in these patients. METHODS: All patients undergoing abdominoplasty by the senior author from January 1, 2005 to January 1, 2012 were retrospectively reviewed. All patients whose operation took place between January 1, 2005 and January 18, 2008 were given SCDs before the induction of anesthesia and heparin (unfractionated) 5000 units s.q. on call to the OR. All patients whose operation took place between January 19, 2008 and January 1, 2012 received enoxaparin (low molecular weight heparin) 40 mg s.q. on call to the OR and then daily for 2 days postoperatively. These groups were evaluated in regards to overall complication rate, incidence of VTE, and bleeding complications. RESULTS: A total of 151 patients underwent abdominoplasty during the study period. One hundred one patients received the SCD/heparin protocol and 50 had the enoxaparin protocol. The groups were similar in regard to pre-morbid conditions and risk factors for VTE. There were no VTEs diagnosed in either group. The overall incidence of any complication was similar between the 2 groups (19% vs. 14%, P = 0.503) and similar to other published series. The most common complications were seroma, cellulitis, and minor wound dehiscence. The incidence of bleeding complications was similar between the 2 groups (1% vs. 0%, P = 1.0). CONCLUSIONS: The use of preoperative chemoprophylaxis in patients undergoing abdominoplasty can be done without an increase in bleeding complications or overall complication rate. Furthermore, enoxaparin can also be used preoperatively and continued for 2 more days during the period of time of maximum immobility with easy administration for outpatients via use of a prescription home use kit.

Rapid measurements of 2,8-dihydroxyadenine (2,8-DHA) with a nanostructured electrochemical sensor in 5-fold diluted supernatants of endothelial cells exposed to oxidative stress.

Fast scan cyclic voltammetry (FSV) with a nanostructured carbon fiber sensor (N-CFS) was developed for direct measurements of the purine metabolite 2,8-dihydroxyadenine (2,8-DHA; i.e. 6-amino-1H-purine-2,8-dione) in endothelial cell supernatants as a marker of cell stress. The 2,8-DHA was measured in the supernatant of aortic (AECs) and pulmonary artery endothelial cells (PAECs), which were maintained in Hank's Balanced Salt solution (HBSS) and exposed to physiological oxygen pressures as well as to oxidative stress, hypoxia (specifically 3% O(2) for AECs) and hyperoxia (20% O(2) for PAECs). Dilution of the supernatants with phosphate buffer in the ratio of 1 : 5 allowed the optimization of FSV measurements with the N-CFS in cell supernatants.The LOD for 2,8-DHA was 1 microM and the LDR was 2-15 microM with the sensitivity of (0.34 +/- 0.01) nA microM(-1) (R(2) = 0.99). The changes in 2,8-DHA concentration when the cells were exposed to stress confirm that PAECs can adapt to stress. However, the results also show that the tolerance of AECs to hypoxia is low. Cellular pathways involved in the response of PAECs and AECs to oxidative stress are outlined.