Improving Skin Paddle Reliability and Muscle Gliding in Free Functional Gracilis Transfers.

Free functional muscle transfer is an attractive option within reconstructive surgery when seeking to restore critical muscle function. The gracilis muscle has long been utilized for this purpose due to its expendability and consistent anatomy. Historically, survival of the skin overlying the distal one-third of the myocutaneous gracilis flap has been unpredictable. To address this, the myofasciocutaneous technique was developed, with prior studies demonstrating improved distal skin paddle viability with this approach; however, the mechanism is poorly defined. This study aimed to understand what factors contribute to survival benefit in myofasciocutaneous gracilis flaps. Using cadaveric dissections followed by latex dye injections, we discuss the creation of a deep fascial sheath that contains a rich vascular network and permits adhesion-free excursion at the recipient site. This study advances our understanding of the myofasciocutaneous gracilis flap and provides wider clinical applicability in free functional muscle transfer.

A Case of Local Radiation Injury in the Creation of Lichtenburg Art.

Despite the fact that there may be no immediate outward signs of tissue destruction, the ultimate damage caused by radiation exposure is immediate and may be predicted based on the source, length of exposure, and type of tissue to which the radiation is exposed. Although predictable, difficulty in caring for these patients stems from the multiple sources of radiation to which people may be exposed, the various parts of the body exposed, the dose involved, the rarity of the condition, and a general lack of knowledge on the part of treating physicians. Due to these factors, there is significant variation in treatment recommendations. Additionally, knowledge about how to treat these injuries is limited and often very difficult to access, even among healthcare professionals. This report highlights the first known case of localized radiation injury secondary to the utilization of a linear accelerator to generate Lichtenberg art. In this case, an accident occurred while working with a retired accelerator and led to severe local radiation injury to this patient's bilateral hands, prompting a series of searches and inquiries as to the next best step in management. From consulting clinicians at the Centers for Disease Control and Prevention (CDC) who are experts in managing radiation injury to the eventual need for digit amputation, this case highlights the profound lack of knowledge and accessible resources for clinicians and patients facing localized radiation injury. This is a noninterventional observation case report without the requirement of ethical approval.

Replantation versus transplantation: Where do we stand?

PURPOSE: Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss. METHODS: Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation. RESULTS: Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use. CONCLUSION: While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.

The Role of Surgery in Oligometastatic Retroperitoneal Sarcoma.

Retroperitoneal sarcomas are extremely rare, comprising <15% of primary sarcomas. Distant metastasis occurs in about 20% of cases, with pulmonary and hepatic metastasis as the most common sites of hematogenous spread. Although surgical resection is well established as the main treatment of localized primary disease, there are limited guidelines for the surgical treatment of intra-abdominal and distant metastases. There are inadequate systemic treatment options for patients with metastatic sarcoma, thereby necessitating the consideration of surgical options in carefully selected patients. Key points to consider include tumor biology, patient fitness and co-morbidities, overall prognosis, and goals of care. Multidisciplinary sarcoma tumor board discussion for each case is an essential practice in order to deliver the best care to these patients. The purpose of this review is to summarize the published literature on the past and present role of surgery in the treatment of oligometastatic retroperitoneal sarcoma in order to inform the management of this difficult disease.

Drop-off in axonal regeneration along the length of a cross-face nerve graft: An experimental study in rats.

INTRODUCTION: The average nerve graft length utilized in cross-face nerve grafting for reconstruction of facial nerve palsy is 20-22 cm. While the graft length is thought to be one of the greatest determinants of muscle strength, the mechanism through which this happens remains unknown. We studied changes in axonal regeneration along the length of a 2 cm cross-face nerve graft in a rat model. The hypothesis was that axon count would decrease along the length of the graft. METHODS: A 2 cm nerve graft (sciatic nerve) was used as a cross-face nerve graft in 16 adult female, 210-250 g, Sprague Dawley rats. Thirteen weeks later, 5 mm nerve biopsies were taken at four sites: the facial nerve trunk (control), proximal graft, midpoint of graft (1 cm distal to coaptation) and distal graft (2 cm distal to coaptation). Retrograde nerve labeling with FluoroGold was performed at the biopsied nerve site and the facial motor nucleus was taken 1 week later. Microscopic imaging and manual counting of axons and labeled motor nuclei was performed. RESULTS: Retrograde-labeled motor neuron counts were decreased at the midway point of the graft compared to the facial trunk (1517 ± 335 axons, Δ% = 92.5, p = .01) and even further decreased at the distal end of the graft (269 ± 293 axons, Δ% = 175.5, p = .006). Analysis of the nerve biopsies demonstrated no significant differences in myelinated axon count between the nerve trunk and over the length of the nerve graft (range 6207-7179 axons, Δ% = 14.5, p = .07). CONCLUSION: In a rat model, the number of regenerating motor neurons drops off along the length of the graft and axon count is preserved due to axon sprouting. How this pattern correlates to ultimate muscle strength remains unknown, but this study provides insight into why shorter grafts may afford better outcomes.

The effect of marijuana use on short-term outcomes with bariatric surgery.

BACKGROUND: Despite increasing marijuana use nationwide, there are limited data on implications of marijuana use on bariatric surgery outcomes. OBJECTIVE: We investigated associations between marijuana use and bariatric surgery outcomes. SETTING: Multicenter statewide study utilizing data from the Michigan Bariatric Surgery Collaborative, a payor-funded consortium including over 40 hospitals and 80 surgeons performing bariatric surgery statewide. METHODS: We analyzed data from the Michigan Bariatric Surgery Collaborative clinical registry on patients who underwent a laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between June 2019 and June 2020. Patients were surveyed at baseline and annually on medication use, depression symptoms, and substance use. Regression analysis was performed to compare 30-day and 1-year outcomes between marijuana users and nonusers. RESULTS: Of 6879 patients, 574 reported baseline marijuana use and 139 reported use at baseline and 1 year. Marijuana users were more likely to be current smokers (14% versus 8%, P < .0001), screen positive for alcohol use disorder (20.0% versus 8.4%, P < .0001), and score higher on the Patient Health Questionnaire-8 (6.1 versus 3.0, P < .0001). There were no statistically significant differences in 30-day outcomes or co-morbidity remission at 1 year. Marijuana users had higher adjusted total mean weight loss (47.6 versus 38.1 kg, P < .0001) and body mass index reduction (17 versus 14 kg/m2, P < .0001). CONCLUSIONS: Marijuana use is not associated with worse 30-day outcomes or 1-year weight loss outcomes and should not be a barrier to bariatric surgery. However, marijuana use is associated with higher rates of smoking, substance use, and depression. These patients may benefit from additional mental health and substance abuse counseling.

A unique treatment of "candy cane" Roux syndrome following Roux-en-Y gastric bypass: a multidisciplinary approach.

Video 1Closure of blind limb after gastric bypass as a treatment for candy cane limb syndrome.

Clinically Important Pharmacologic Considerations for Wide Awake Local No Tourniquet (WALANT) Hand Surgery.

Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications utilized in surgery will help surgeons to utilize them more safely and effectively. The goal of this article is to provide an overview of these considerations for the two medications, lidocaine, and epinephrine, utilized in Wide Awake Local Anesthesia No Tourniquet (WALANT) upper extremity surgery. After review of this article, the reader should have a better understanding of lidocaine and epinephrine for tumescent local anesthesia, as well as adverse reactions and how to manage them.

Alternative Nerve Transfer for Shoulder Function: Thoracodorsal and Medial Triceps to Anterior Axillary Nerve.

We describe a reliable approach for double nerve transfer of the medial triceps branch and thoracodorsal nerve to the axillary nerve to increase axonal input. We present a review of outcomes for both end-to-end and reverse end-to-side nerve transfer. Methods: A retrospective review of patients who underwent nerve transfer for improvement of shoulder abduction at Harborview Medical Center and Northwestern Memorial Hospital between 2012 and 2021 was conducted. Patients were prospectively contacted to fill out a 30 item Disabilities of the Arm, Shoulder and Hand questionnaire, with an option to upload a video demonstrating active range of motion. Results: Twenty-one patients with 23 affected extremities were included in the final analysis. Fifteen patients completed the prospective arm of the study (71% response rate). Seventy-nine percent of patient limbs achieved a Medical Research Council Motor Scale (MRC-MS) of 4 or greater, and measured shoulder abduction active range of motion (AROM) was 139.2 degrees (range, 29-174 degrees) and 140.9 degrees (range, 60-180 degrees) (P = 0.95) for end-to-end and reverse end-to-side, respectively. Comparing end-to-end with reverse end-to-side neurorrhaphy, outcomes, including follow-up, mean postoperative MRC-MS, mean change in MRC-MS, Disabilities of the Arm, Shoulder and Hand, abduction AROM, and flexion AROM, were not statistically different. Conclusions: We showed improvements in shoulder abduction with the thoracodorsal nerve, in addition to the medial triceps branch, to increase axonal donation and power the axillary nerve without sacrificing the spinal accessory nerve. Furthermore, we demonstrated improvements with reverse end-to-side coaptation when intraoperative stimulation of the axillary nerve revealed residual function.

Decisional Regret Among Patients Undergoing Colectomy.

BACKGROUND: Patients undergoing colectomy may be at risk for postoperative regret, which is associated with worse quality of life, higher rates of depression, and poorer health outcomes. A better understanding of factors associated with decisional regret may allow surgeons to better tailor preoperative discussions to mitigate the risk of regret. OBJECTIVE: This study aimed to identify factors associated with regret in patients undergoing elective and urgent/emergent colectomy. DESIGN: A retrospective cohort study. SETTING: The Michigan Surgical Quality Collaborative, a 73-hospital collaborative, which collects clinical data on general surgery operations. PATIENTS: Patients aged >18 years who underwent elective or urgent/emergent colectomy between January 2017 and March 2020 and who completed a decision regret survey. MAIN OUTCOME MEASURES: Any degree of postoperative regret. RESULTS: Of 3638 patients, 2,530 (70%) underwent elective and 1108 (30%) underwent urgent/emergent colectomy. Overall, 381 (10.5%) patients reported regret, with higher rates among the urgent/emergent setting compared with the elective cohort (13.0% vs 9.4%; p < 0.001). In the elective cohort, regret was associated with length of stay >7 days (OR, 2.32; 95% CI, 1.06-5.07), postoperative complication (OR, 1.95; 95% CI, 1.36-2.79), and readmission (OR, 1.90; 95% CI, 1.22-2.95). Elective colectomies for cancer/adenoma/polyp were associated with lower odds of regret (OR, 0.68; 95% CI, 0.50-0.91). In the urgent/emergent cohort, regret was associated with female sex (OR, 1.69; 95% CI, 1.15-2.50) and nonhome discharge destination (OR, 1.61; 95% CI, 0.04-1.03). LIMITATIONS: Hospitals used different sampling strategies, limiting our ability to calculate a true response rate and characterize nonresponders. CONCLUSIONS: One in 10 patients reported regret after colectomy with higher rates in those undergoing urgent/emergent colectomy. Factors associated with regret were different between surgical settings. Efforts are needed to mitigate patients' risk of regret with individualized discussions contingent on surgical settings to better align expectations and outcomes. See Video Abstract at http://links.lww.com/DCR/C3 . ARREPENTIMIENTO DEL PACIENTE EN LA DECISIN DE SOMETIMIENTO A COLECTOMA: ANTECEDENTES:Los pacientes que se someten a una colectomía pueden estar en riesgo de arrepentimiento post operatorio, la cual está asociada con una peor calidad de vida, mayores tasas de depresión y peores resultados de salud. Una mejor comprensión de los factores asociados con el arrepentimiento de dicha decisión, puede permitir a los cirujanos adaptar de una mejor manera las discusiones preoperatorias y así mitigar el riesgo de arrepentimiento.OBJETIVO:Identificar factores asociados al arrepentimiento en pacientes sometidos a colectomía electiva y urgente/emergente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:The Michigan Surgical Quality Collaborative, una colaboración de 73 hospitales.PACIENTES:Pacientes ≥18 años sometidos a colectomía electiva o urgente/emergente entre enero de 2017 y marzo de 2020, y que hayan completado una encuesta de arrepentimiento en cuanto a la decisión.PRINCIPALES MEDIDAS DE RESULTADO:Reporte de cualquier grado de arrepentimiento postoperatorio.RESULTADOS:De 3.638 pacientes, 2.530 (70%) fueron sometidos a colectomía electiva y 1.108 (30%) a colectomía urgente/emergente. En general, 381 (10,5%) pacientes informaron arrepentimiento, con tasas más altas en el grupo relacionado con el escenario urgente/emergente en comparación con la cohorte electiva (13,0% frente a 9,4%, p < 0,001). En la cohorte electiva, el arrepentimiento se asoció con una estancia hospitalaria >7 días (OR 2,32, IC 95% 1,06-5,07), complicación posoperatoria (OR 1,95, IC 95% 1,36-2,79) y reingreso (OR 1,90, IC 95% 1,22-2,95). Las colectomías electivas por cáncer/adenoma/pólipo se asociaron con una menor probabilidad de arrepentimiento (OR 0,68, IC 95%: 0,50-0,91). En la cohorte urgente/emergente, el arrepentimiento se asoció con el sexo femenino (OR 1,69, IC 95% 1,15-2,50) y el destino del alta no domiciliario (OR 1,61, IC 95% 0,04-1,03).LIMITACIONES:Los hospitales utilizaron diferentes estrategias de muestreo, lo que limita nuestra capacidad para calcular una tasa de respuesta real y caracterizar a los que no respondieron.CONCLUSIONES:Uno de cada diez pacientes reportó arrepentimiento después de la colectomía con tasas más altas en aquellos sometidos a colectomía urgente/emergente. Los factores asociados con el arrepentimiento fueron diferentes entre los entornos quirúrgicos. Se necesitan esfuerzos para mitigar el riesgo de arrepentimiento de los pacientes con discusiones individualizadas supeditadas al entorno quirúrgico para caracterizar de una mejor las expectativas y los resultados. Consulte Video Resumen en http://links.lww.com/DCR/C3 . (Traducción-Dr. Osvaldo Gauto).

Objective assessment of luminal diameter and distensibility by an impedance planimetry system before and after pneumatic dilation in gastric sleeve stenosis.

Video 1Endoscopic impedance planimetry system measurement and pneumatic balloon dilation of a sleeve gastrectomy stricture.

The Importance of Mentorship in Shaping the Careers of Academic Leaders in Plastic Surgery.

BACKGROUND: The majority of successful academic physicians cite mentorship as a critical element of their achievements. The goal of this study was to survey established leaders in plastic surgery to identify the importance that mentorship played in their career development, and to identify common themes that enabled them to "pay it forward" in helping to develop the next generation of leaders in plastic surgery. METHODS: The authors performed a qualitative survey of 14 established leaders in plastic surgery (mentors) in the United States with a strong reputation for mentorship. The authors asked each to identify a key mentor (senior mentor) and mentee, grouping them in triads of a senior mentor, mentor, and mentee. The authors then submitted a similar survey to the mentee. RESULTS: Thirteen mentor-mentee pairs for which both members had responded were included. After reviewing responses to these questions, the authors elicited a number of recurring themes. All respondents emphasized the importance of mentorship to their success in academic plastic surgery. Additional themes included encouraging mentees to find their passion, leading by example, discussing complex cases with residents/students, and using research time as an opportunity. CONCLUSIONS: Strong patterns of mentorship are highlighted among the careers of leaders in academic plastic surgery. The authors advocate for formation of mentorship relationships within training programs and more national mentorship programs such as those emerging through the American Society of Plastic Surgeons and the Plastic Surgery Research Council for interested medical students, residents, and junior faculty.

An In Vivo Comparison: Novel Mesh Suture Versus Traditional Suture-Based Repair in a Rabbit Tendon Model.

Purpose: Despite advancements in surgical techniques, suture pull-though and rupture continue to limit the early range of motion and functional rehabilitation after flexor tendon repairs. The aim of this study was to evaluate a suturable mesh compared with a commonly used braided suture in an in vivo rabbit intrasynovial tendon model. Methods: Twenty-four New Zealand female rabbits (3-4 kg) were injected with 2 units/kg botulinum toxin evenly distributed into 4 sites in the left calf. After 1 week, the animals underwent surgical tenotomy of the flexor digitorum tendon and were randomized to repair with either 2-0 Duramesh suturable mesh or to 2-0 Fiberwire using a 2-strand modified Kessler and 6-0 polypropylene running epitendinous suture. Rabbits were killed at 2, 4, and 9 weeks after surgery. Results: Grouping across time points, 58.3% (7 of 12) of Duramesh repairs were found to be intact for the explant compared with 16.7% (2 of 12) of Fiberwire repairs (P = .09). At 2 weeks, the mean Duramesh repairs were significantly stronger than the Fiberwire repairs with a mean failure load of 50.7 ± 12.7 N compared to 14.8 ± 18.3 N (P = .02). The load supported by the Duramesh repairs at 2 weeks (mean 50.7 ± 12.7 N) was similar to the load supported by both Fiberwire (52.2 ± 13.6 N) and Duramesh (57.6 ± 22.3 N) at 4 weeks. The strength of repair between Fiberwire and Duramesh at 4 weeks and 9 weeks was not significantly different. Conclusions: The 2-strand tendon repair with suturable mesh achieved significantly greater strength at 2 weeks than the conventional suture material. Future studies should evaluate the strength of repair prior to 2 weeks to determine the strength curve for this novel suture material. Clinical Relevance: This study evaluates the utility of a novel suturable mesh for flexor tendon repair in an in vivo rabbit model compared with conventional suture material.

Establishment of Objective Clinical Parameters for Assessment of Trigonocephaly: Are Caliper-Derived Clinical Measures Adequate?

OBJECTIVE: Objective clinical parameters characterizing the severity of trigonocephaly are essential given the concern for computerized tomography (CT) scans and radiation in infants. The present study seeks to develop a clinical tool by which to characterize trigonocephaly. DESIGN: Retrospective cohort study. SETTING: Tertiary academically affiliated children's medical center. PARTICIPANTS: A retrospective review identified patients with trigonocephaly for whom surgery was recommended (group 1) and those with metopic ridging without significant trigonocephaly (group 2). Normal age-matched controls were also evaluated (group 3). INTERVENTIONS: Cranial vault caliper measurements were compared across groups. Two ratios measuring anterior vault constriction were developed: (1) bitemporal width at the mid-forehead to the biparietal width, and (2) bitemporal width at the lateral brow to the biparietal width. MAIN OUTCOME MEASURES: Bitemporal width to biparietal width (ratio). RESULTS: Caliper measures were obtained from 19 patients in group 1, 8 patients in group 2, and 19 patients in group 3 (controls). Cranial indices were not significantly different across groups. The bitemporal width at the mid-forehead to the biparietal width ratio was significantly lower in group 1, with no difference between groups 2 and 3. The bitemporal width at the lateral brow to the biparietal width ratio was significantly different between all 3 groups, with group 1 < group 2 < group 3, respectively. CONCLUSIONS: Bitemporal to biparietal ratios are a quantitative, objective clinical measure that can be used to differentiate patients with significant trigonocephaly from those with metopic ridging but no significant cranial deformity. These findings suggest that caliper-derived indices can assist in characterizing surgically relevant cranial vault deformities secondary to metopic synostosis and may circumvent CT-based analysis.

Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication.

Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. METHODS: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last set of office photographs. RESULTS: Surgical site occurrence rate was 0% of the 40 patients in the mesh group and 19% of the 37 patients in the standard group (P = 0.005); rates of soft-tissue revision were 23% in the mesh group and 27% in the standard group (P = 0.84). As to aesthetics, the mesh abdominoplasty patients had mean statistically lower preoperative scores in comparison with the standard plication group (65.8 ± 11.6 versus 70.3 ± 11.4, P = 0.0013). The mesh group had a statistical improvement to 75.9 ± 12.6 (P < 0.0001), whereas the standard plication group improved to 82.5 ± 11.4 (P < 0.0001). CONCLUSIONS: Retrorectus mesh placement in a cohort of patients with severe rectus diastasis had a complication rate lower than that seen in a cohort of patients with less severe rectus diastasis, therefore negating our original hypothesis. This was done without compromising aesthetic improvement.

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.

The Relationship Between Dental Agenesis and Maxillary Hypoplasia in Patients With Cleft Lip and Palate.

ABSTRACT: Both dental agenesis and maxillary growth restriction are well-recognized sequelae in patients with unilateral cleft lip and palate, but their etiology remains controversial. The aim of this study was to evaluate the relationship between hypodontia and maxillary volume. A retrospective review of patients age 6 to 9 with Veau III (unilateral) cleft palate who underwent Cone Beam Computer Tomography in preparation for alveolar bone grafting at 2 major Children's Hospitals between 2010 and 2016 was conducted and serial panoramic radiographs were reviewed. Thirty-eight patients were identified that met inclusion criteria and had adequate imaging. Group 1 ("poor growers") consisted of the bottom 50% of Sella-Nasion-A point minus Sella-Nasion-B point (ANB) angles and Group 2 ("good growers") consisted of the top 50% of ANB angles. Group 1 had a significantly higher mean number of missing teeth (1.58 ±â€Š0.28 missing teeth) compared to Group 2 (0.74 ±â€Š0.23 missing teeth), and significantly lower maxillary volume (12.88 ±â€Š0.61 cm3 versus 15.24 ±â€Š0.88 cm3, respectively). The severity of maxillary hypoplasia in cleft patients increases with increased dental agenesis. These data indicate that intrinsic factors play a significant role in maxillary growth restriction in cleft patients, independent of the sequelae of surgical intervention.

Current Use of Cosmetic Toxins to Improve Facial Aesthetics.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin. SUMMARY: Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.

Advanced Materials in Wireless, Implantable Electrical Stimulators That Offer Rapid Rates of Bioresorption for Peripheral Axon Regeneration.

Injured peripheral nerves typically exhibit unsatisfactory and incomplete functional outcomes, and there are no clinically approved therapies for improving regeneration. Post-operative electrical stimulation (ES) increases axon regrowth, but practical challenges from the cost of extended operating room time to the risks and pitfalls associated with transcutaneous wire placement have prevented broad clinical adoption. This study presents a possible solution in the form of advanced bioresorbable materials for thin, flexible, wireless implant that provides precisely controlled ES of the injured nerve for a brief time in the immediate post-operative period. Afterward, rapid, complete and safe modes of bioresorption naturally and quickly eliminate all of the constituent materials in their entirety, without the need for surgical extraction. The unusually high rate of bioresorption follows from the use of a unique, bilayer enclosure that combines two distinct formulations of a biocompatible form of polyanhydride as an encapsulating structure, to accelerate the resorption of active components and confine fragments until complete resorption. Results from mouse models of tibial nerve transection with re-anastomosis indicate that this system offers levels of performance and efficacy that match those of conventional wired stimulators, but without the need to extend the operative period or to extract the device hardware.

Novel Approach of Mandibular Distraction to Avoid Tracheostomy in KAT6B-related Gene Disorders.

Previously, severe upper airway obstruction in patients with retrognathia and glossoptosis has been managed with tracheostomy. However, tracheostomy is associated with significant morbidity. In recent years, mandibular distraction has become an alternative management strategy in infants, but these applications have been limited to patient populations with retrognathia and glossoptosis. The authors present 2 unique cases of patients with KAT6B-related gene disorders, who present with a paradox of tongue-based airway obstruction in the absence of retrognathia. In both cases mandibular distraction osteogenesis with an obliquely oriented vector was successfully performed and both children avoided the need for tracheostomy.