"Toward Breast Reinnervation- What is our Endpoint" A systematic review of normal breast sensibility.

BACKGROUND: To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement. METHODS: We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated. RESULTS: A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility. CONCLUSIONS: The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.

Isolated Spinal Accessory Nerve Palsy from Volleyball Injury.

Spinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy.

Morgellons Disease: The Spread of a Mass Psychogenic Illness via the Internet and Its Implications in Hand Surgery.

Somatic manifestations of mental illness sometimes occur in patients presenting to hand specialists. These conversion disorders can also occur in groups, a phenomenon known as "mass psychogenic illness." The increasing penetrance of the Internet and social media in modern society has greatly facilitated the interaction of patients with others with similar disorders. One example relevant to hand surgery is "Morgellons disease," a disorder popularized in 2002 and characterized by a firm belief in foreign material extruding from the skin, leading to nonhealing, self-inflicted ulcerations and excoriations. A series of 4 patients collected through an informal survey of hand surgeons regarding experience with Morgellons disease is reviewed and discussed. All patients in the series presented with a chief complaint of foreign material extruding from the hand. In 1 case, the complaint was made by a young patient's mother. In none of the patients were foreign bodies identified, although 2 patients demonstrated significant ulcerations and scars from self-excoriation. Three patients had a somatic condition affecting the hand or upper extremity, 1 directly related to self-excoriation and 2 unrelated. Treatments, workups, and ultimate outcomes varied among patients. Patients presenting with Morgellons disease often undergo multiple unnecessary tests and are at risk of inappropriate procedures. It is therefore important that providers have a compassionate understanding of the involved psychology. Herein, we offer an approach to the recognition of and treatment strategies for these patients.

Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas.

Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6-128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

Hybrid conducting polymer-hydrogel conduits for axonal growth and neural tissue engineering.

Successfully and efficiently bridging peripheral nerve gaps without the use of autografts is a substantial clinical advance for peripheral nerve reconstructions. Novel templating methods for the fabrication of conductive hydrogel guidance channels for axonal regeneration are designed and developed. PEDOT is electrodeposited inside the lumen to create fully coated-PEDOT agarose conduits and partially coated-PEDOT agarose conduits.

Microscale electrode implantation during nerve repair: effects on nerve morphology, electromyography, and recovery of muscle contractile function.

BACKGROUND: The authors' goal is to develop a peripheral nerve electrode with long-term stability and fidelity for use in nerve/machine interfaces. Microelectromechanical systems use silicon probes that contain multichannel actuators, sensors, and electronics. The authors tested the null hypothesis that implantation of microelectromechanical systems probes does not have a detrimental effect on peripheral nerve function or regeneration. METHODS: A rat hind-limb, peroneal nerve model was used in all experimental groups: intact nerve (control group, n=10); nerve division and repair (repair group, n=9); and nerve division, insertion of microelectromechanical systems probe, and repair (repair plus probe group, n=9). Nerve morphology, nerve to compound muscle action potential studies, walking tracks, and extensor digitorum longus muscle function tests were evaluated following an 80-day recovery. RESULTS: Repair and repair plus probe showed no differences in axon count, axon size, percentage nonneural area, compound muscle action potential amplitude, latency, muscle mass, muscle force, or walking track scores. Although there was some local fibrosis around each microelectromechanical systems probe, this did not lead to measurable detrimental effects in any anatomical or functional outcome measurements. CONCLUSION: The absence of a significant difference between the repair and the repair plus probe groups regarding histology, compound muscle action potential, walking tracks, and muscle force suggests that microelectromechanical systems electrodes are compatible with regenerating axons and show promise for establishing chemical and electrical interfaces with peripheral nerves.

The keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruction.

BACKGROUND: Microsurgical perforator flaps are useful in an array of reconstructive scenarios, but their technical complexity, steep learning curves, and prolonged operative times may limit their widespread adoption. Alternatively, the keystone island flap combines perforator-based vascularity with relative simplicity of nonmicrosurgical tissue rearrangement. This article reviews the authors' reconstructive experience using the keystone flap to reconstruct large trunk and extremity defects. METHODS: The authors performed a retrospective chart review of patients undergoing keystone flap reconstruction between 2002 and 2008. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications, and follow-up care were evaluated and are presented in this article as an uncontrolled case series. RESULTS: Twenty-eight patients underwent keystone flap reconstruction. The average wound size measured 15.0 ± 11.7 × 13.0 ± 7.9 cm (250.5 ± 379.4 cm2). The average length of stay, including tumor resection, was 6.36 ± 6.68 days. A 35.7 percent overall complication rate was noted; partial and total flap loss was observed in only 7 percent of patients. One patient (3 percent) failed reconstruction and required alternative wound closure. CONCLUSIONS: The keystone flap can be applied to large defects of the trunk and extremities, obviating the need for either microsurgical techniques or extensive operative time while achieving primary wound healing. Despite minor complications, the 97 percent reconstructive success rate compares well to published rates of microsurgical tissue transfers but has several advantages: short operative times, high reproducibility, ease of use, and favorable aesthetic outcome. The authors conclude that the keystone flap is a reliable and effective reconstructive surgical technique for reconstruction of soft-tissue defects.

Horizontal misalignment in patients with unilateral superior oblique palsy.

PURPOSE: To determine the frequency and distribution of horizontal misalignment in patients with unilateral superior oblique palsy (SOP) and to determine the indications for combining horizontal with vertical strabismus surgery. METHODS: Patients included in the study had a vertical heterophoria or tropia that fit Parks three-step test for SOP and had no previous strabismus surgery or other ocular motility disturbance. Ocular motility and alignment were recorded. Outcomes between patients who had vertical surgery alone and those who had combined vertical and horizontal surgery were compared using the Student's t test. RESULTS: Of 205 patients, 121 (59.0%) had a horizontal misalignment in addition to vertical strabismus. Ninety-six patients (46.8%) required strabismus surgery. Of these, 29 had 8 prism diopters (PD) or more horizontal deviation. Twenty-two had vertical combined with horizontal surgery (V+H group). Although their initial deviation was greater, these patients had better surgical outcomes than patients who had vertical surgery alone (V group). The V+H group had a final mean horizontal deviation of 2.18 PD compared with 6.85 PD in the V group (P < .01). Postoperative vertical alignment in the V+H group was also superior with a final mean vertical deviation of 3.7 versus 6.8 PD for the V group (P = .12). CONCLUSION: These results indicate that horizontal misalignment is common in patients with SOP. Patients with 8 PD or more horizontal deviation benefited from surgical correction of the horizontal deviation in addition to the vertical surgery.

In vivo electrical conductivity across critical nerve gaps using poly(3,4-ethylenedioxythiophene)-coated neural interfaces.

BACKGROUND: Bionic limbs require sensitive, durable, and physiologically relevant bidirectional control interfaces. Modern central nervous system interfacing is high risk, low fidelity, and failure prone. Peripheral nervous system interfaces will mitigate this risk and increase fidelity by greatly simplifying signal interpretation and delivery. This study evaluates in vivo relevance of a hybrid peripheral nervous system interface consisting of biological acellular muscle scaffolds made electrically conductive using poly(3,4-ethylenedioxythiophene). METHODS: Peripheral nervous system interfaces were tested in vivo using the rat hind-limb conduction-gap model for motor (peroneal) and sensory (sural) nerves. Experimental groups included acellular muscle, iron(III) chloride-treated acellular muscle, and poly(3,4-ethylenedioxythiophene) polymerized on acellular muscle, each compared with intact nerve, autogenous nerve graft, and empty (nonreconstructed) nerve gap controls (n=5 for each). Interface lengths tested included 0, 5, 10, and 20 mm. Immediately following implantation, the interface underwent electrophysiologic characterization in vivo using nerve conduction studies, compound muscle action potentials, and antidromic sensory nerve action potentials. RESULTS: Both efferent and afferent electrophysiology demonstrates acellular muscle-poly(3,4-ethylenedioxythiophene) interfaces conduct physiologic action potentials across nerve conduction gaps of at least 20 mm with amplitude and latency not differing from intact nerve or nerve grafts, with the exception of increased velocity in the acellular muscle-poly(3,4-ethylenedioxythiophene) interfaces. CONCLUSIONS: Nonmetallic, biosynthetic acellular muscle-poly(3,4-ethylenedioxythiophene) peripheral nervous system interfaces both sense and stimulate physiologically relevant efferent and afferent action potentials in vivo. This demonstrates their relevance not only as a nerve-electronic coupling device capable of reaching the long-sought goal of closed-loop neural control of a prosthetic limb, but also in a multitude of other bioelectrical applications.

A minimally invasive approach to the placement of tissue expanders.

Plastic surgeons are frequently faced with difficult and challenging soft tissue defects in all areas of the body. To reconstruct these defects, there are many operative approaches available to the reconstructive surgeon including skin grafts, local flaps, regional flaps, and free-tissue transfer. Despite these many options, occasionally the best alternative for reconstruction of a wound is tissue expansion, where skin of similar quality, texture, and color can be used to close a soft tissue defect. Unfortunately, there are significant problems related to tissue expander reconstruction including a complication rate as high as 50%. As a result, tissue expander reconstruction has not achieved the widespread popularity commensurate with its potential clinical utility. To reduce the complication rate related to open tissue expander placement, and consequently to improve its clinical utility, we have employed endoscopic techniques for the placement of tissue expanders. Endoscopic approaches are currently being used in many areas of surgery and have resulted in substantial benefits. Endoscopic placement of tissue expanders has the benefit of reducing operative time, major complication rate, time to full expansion, and length of hospital stay. The purpose of this article is to critically examine the current open technique for tissue expander placement and to compare this technique with minimally invasive endoscopic tissue expander placement. We will discuss in detail the current problems associated with open tissue expander placement, the benefits of endoscopic tissue expansion, the technique of endoscopic tissue expander placement, and the outcomes for these techniques.