Reliability of Long Vein Grafts for Reconstruction of Massive Wounds.

When handling large wounds, zone of injury is a key concept in reconstructive microsurgery, as it pertains to the selection of recipient vessels. Historically, surgeons have avoided placing microvascular anastomosis within widely traumatized, inflamed, or radiated fields. The harvest of vein grafts facilitates reconstruction in complex cases by extending arterial and/or venous pedicle length. To illustrate the utility and fidelity of these techniques, this paper reviews the indications and outcomes for vein grafting in ten consecutive patients at a single tertiary referral center hospital. The case series presented is unique in three aspects. First, there are two cases of successful coaptation of the flap artery to the side of the arterial limb of an arteriovenous loop. Second, there is a large proportion of cases where vein grafts were used to elongate the venous pedicle. In these 10 cases, the mean vein graft length was 37 cm. We observed zero flap failures and zero amputations. Although limited in sample size, these case data support the efficacy and reliability of long segment vein grafting in complex cases in referral centers.

Lower Extremity Microsurgery in a Patient With Combined Sickle Cell Disease and Hemophilia: A Case Report and Literature Review.

The combination of hemophilia and sickle cell disease poses unique challenges in the perioperative management of patients requiring free tissue transfer (FTT). Extremity FTT requires mitigation of risk factors related to perioperative bleeding and microvascular thrombosis. This case report highlights the nuances of managing an open ankle fracture in a patient with both sickle cell trait and severe hemophilia A. The narrative and discussion highlights the importance of a multidisciplinary team with regard to executing a limb salvage plan in the setting of complex medical decision-making.

Lower Extremity Salvage in a Diabetic Patient With Cutaneous Mucormycosis and COVID-19 After Open Patella Fracture.

Background: Cutaneous mucormycosis, while less common than sinonasal or pulmonary infections, can cause widespread tissue necrosis after seemingly innocuous encounters. The most common location of cutaneous mucormycosis is the extremities, and extensive infection has been reported after trauma or orthopedic procedures. Case Report: A 60-year-old female with poorly controlled type 2 diabetes mellitus sustained an open patella fracture after a fall. She underwent washout and internal fixation with cannulated screws and cable tension band wiring. The patient's recovery was complicated by asymptomatic coronavirus disease 2019 (COVID-19) infection and repeated wound dehiscence, with growth of Mucor species initially presumed to be a contaminant. Despite serial washout and debridement, repeat dehiscence and patella exposure were noted. Free tissue transfer to the genicular vessels was selected for coverage of the extensor tendon, patella, and fracture line. In repeat skin cultures, Mucor indicus and Staphylococcus epidermidis grew from the wound. Topical voriconazole and a 6-week course of intravenous isavuconazole and oral doxycycline were started when the Mucor cultures were identified. Conclusion: This case highlights an approach to an indolent mucormycosis infection in the skin over a patella fracture in a patient with poorly controlled diabetes mellitus, including the sequence of surgical care, debridement, and selection of antimicrobials. Major amputation and orthopedic revision were avoided. This patient also underwent successful free tissue transfer after testing positive for COVID-19.

A Propeller Perforator Flap in the Distal Lower Extremity: An Alternative to Free Flap Coverage Near the Ankle.

As perfusion assessment technologies and microsurgical techniques have evolved, plastic surgeons have become increasingly aggressive and creative in offering reconstructive solutions to limb salvage problems. In the distal lower extremity, pedicled perforator flap transfer has grown in popularity as compared to the historically reliable option of free tissue transfer. Pedicled perforator flaps typically avoid muscle harvest and restore the thin, supple soft tissue in the distal extremity, where there is a relative lack of redundancy of soft tissues. They also allow for a shorter operative time and recovery in otherwise complex wounds of the foot and ankle. This case report highlights the indications, nuance, and post-operative course of a patient who underwent peroneal perforator flap for coverage of a complex ankle wound in the setting of a calcaneal fracture.

Successful Salvage of Delayed Venous Congestion After DIEP Flap Breast Reconstruction.

Objective: Failure rates of microvascular autologous breast reconstruction are reportedly low. When failure of the microvascular anastomoses does occur, it is most likely to be salvaged if detected early. Flap compromise or venous congestion occurring several weeks later is uncommon and with significantly lower salvage rates. Methods: We present a unique case of delayed venous congestion of a single-perforator deep inferior epigastric perforator flap breast reconstruction in which the usual pedicle thrombosis was not identified. Presentation of the flap compromise occurred 72 hours postoperatively and again in the delayed setting 5 weeks after surgery, from suspected compression at the perforator level. Results: The deep inferior epigastric perforator flap was successfully salvaged with conservative measures, and the flap healed without fat necrosis or further complication. Conclusion: This case highlights the higher risk of flap compromise with reconstructions in a radiated field and potentially with single-perforator flaps.

Neck Contouring Without Rhytidectomy in the Presence of Excess Skin.

BACKGROUND: Patients with severe neck skin laxity due to excess submental adipose tissue have required either standard rhytidectomy or direct excision of neck skin with Z-plasty and submental lipectomy. Our recent experiences with four patients who declined cervicofacial rhytidectomy demonstrate that submental lipectomy and platysmarrhaphy appear to obtain sufficient improvement. METHODS: The submental area, submandibular area, and lateral neck are injected with local anesthetic. An incision is made in the submental area anterior to the existing crease, and the incision is taken through the subcutaneous tissue to the underlying fat. The skin is undermined in the deep subcutaneous plane. The lateral fat that cannot be visualized directly is suctioned using a number 2 cannula. Supra-platysmal and subplatysmal excess fat are excised under direct vision. The anterior bellies of the digastric muscle are excised partially or completely to obtain a flat contour if necessary. The submaxillary gland is partially or totally removed as indicated. The platysmarrhaphy is performed, and a TLS drain is placed in position and brought out through the left post-auricular sulcus using the attached trocar. The submental incision is then closed without skin excision. RESULT: Non-excisional surgical neck rejuvenation was performed on four patients with significant skin laxity. There was adequate improvement in the cervicomental angle and neck profile contour in all patients, indicating that significant improvement may be achieved without skin excision. CONCLUSION: Patients with excess skin can achieve acceptable results with submental lipectomy and platysmarrhaphy without rhytidectomy or direct excision of neck skin. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Local Coverage for Acute Severely Herniated Brain Using Scalp and Forehead Flaps in a Pediatric Patient With Head Trauma.

A 4-year-old-boy required emergent craniectomy and drainage of a large right-sided acute subdural hematoma after head trauma, during which massive sinus hemorrhage with brain swelling occurred. Acute intraoperative management entailed dural cover using synthetic dural membrane substitute and scalp coverage over the herniated brain using acellular dermal matrix. After intensive monitoring and control of raised intracranial pressure over the next few days, the exposed brain was then covered by scalp and forehead flaps with cadaveric skin grafting to the donor site. This temporary coverage continued until adequate resolution of the intracranial swelling and control of the hydrocephalus using a ventriculoperitoneal shunt. Ultimately, the flaps were derotated and the craniectomy site was reconstructed with autologous banked bone. The child had a significant functional recovery with some residual left-sided weakness. This case is the first report of local tissue flaps used for temporary coverage of malignant brain herniation in a pediatric head trauma patient and highlights their effective use. Through serial surgical procedures the brain was successfully covered without significant blood loss and the patient's local tissues returned to their original donor sites with good cosmetic outcome, without sacrifice of the patient's own skin or free flap options.

Three-Dimensional Changes in the Midface Following Malar Calcium Hydroxyapatite Injection in a Cadaver Model.

BACKGROUND: Three-dimensional (3D) changes in the midface following malar calcium hydroxyapatite (CaHa) injection have not been systematically analyzed. OBJECTIVES: The authors analyzed 3D volume changes in midface and naso-labial fold (NLF) volume, as well as lateral movement in the NLF/naso-labial crease (NLC) junction following malar injection of CaHa in a cadaver model. METHODS: A single surgeon injected CaHa in the supraperiosteal plane. Sequential images were obtained with the VECTRA 3D system pre- and post-1.5- and 3-cc CaHa injections. All measurements were performed by a single examiner. Injection location was verified anatomically. RESULTS: Injections were performed in 16 fresh cadaver hemi-faces. Maximal increases in projection were centered on the malar injection site, with associated decreases in projection and volume in the infero-medial locations. Relative mean increases in volume of 3.16 cc and 4.94 cc were observed following the 1.5-cc and 3-cc injections, respectively. There was a relative decrease in the volume of the NLF of -0.3 cc and -0.4 cc following the 1.5- and 3-cc injections, respectively. Injection of CaHa was associated with lateral movements of the NLF-NLC junction at the level of the nasal sill, philtral columns, and oral commissure, measuring 2.7, 2.5, and 1.9 mm and 2.8, 2.9, and 2.4 mm following the 1.5- and 3-cc injections, respectively. Anatomical dissection verified the location in the supraperiosteal space and within the middle malar fat pad. CONCLUSIONS: Following malar CaHa injection, 3D photographic analysis showed a measureable lifting effect with recruitment of ptotic tissue and lateral movement of the NLF-NLC junction in a cadaver model.

Contemporary techniques for effective nasal lengthening.

The short nose deformity is a complex entity with diverse causes and variable characteristics. This article divides shortening into anterior and pan-nose shortening as well as mild, moderate, or severe. Mild anterior shortening can be corrected with shield grafting, whereas moderate to severe shortening can be corrected using septal extension grafts, composite grafts, or the tongue-and-groove technique. Ancillary technical considerations are reviewed. General principles of patient assessment and rhinoplasty execution are discussed. Surgical cases are presented, and pertinent aspects of preoperative planning, surgical technique, and perioperative care are discussed.

Quantifying sulcal and gyral topography in relation to deep seated and ventricular lesions: cadaveric study for basing surgical approaches and review of literature.

OBJECTIVE: Numerical implication of sulcal and gyral topography for surgical approaches has not been studied. METHODS: Percentage gain of distance using sulci as compared to that of gyri was calculated by measuring distances toward the ventricles in 15 hemispheres. RESULTS: Superior frontal sulcus was closest proving greater than 50% gain in distance compared to superior frontal gyrus; inferior temporal sulcus provided greater gain in the temporal lobe. CONCLUSION: Sulci provide upto 58% distance gain. For trans-gyral approaches, MFG and ITG were found closer to the respective ventricular area.

The deviated nose and asymmetric eyebrows: an important trap to avoid.

BACKGROUND: Failure to recognize asymmetrically positioned eyebrows, often altered by the patient to camouflage nasal asymmetry, can lead the surgeon to design the rhinoplasty using a faulty midline landmark. The purpose of this study was to investigate the frequency of eyebrow asymmetry and to test whether there is an association between eyebrow position and the direction of nasal deviation. METHODS: Life-size photographs of 100 rhinoplasty patients were selected randomly from the senior author's (B.G.) practice. Nasal deviation from the midpoint of the intercanthal distance was measured at standardized levels on anteroposterior views corresponding to the nasal bones, upper lateral cartilages, and nasal tip. The maximally deviated parameter was noted. RESULTS: Of the 27 men and 73 women studied, 96 patients had measurable eyebrow asymmetry, including 96 percent of men and 96 percent of women. All 100 patients had at least one level of nasal deviation. The direction of eyebrow shift correlated significantly with the direction of nasal deviation for nasal bones (p = 0.0018), nasal tip (p = 0.0032), and maximally deviated parameter (p = 0.039), but not for upper lateral cartilages (p = 0.54). Mean eyebrow shift distance for male patients (1.8 mm) and female patients (1.3 mm) was not significantly different (p = 0.056). CONCLUSIONS: The frequency of eyebrow asymmetry and the significant correlation between eyebrow position and nasal deviation direction suggest that eyebrows can camouflage nasal deformities. Furthermore, the alarmingly high incidence of nasal deviation in rhinoplasty candidates emphasizes the value of a circumspect preoperative nasal analysis in reducing the incidence of residual postoperative nose deviation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Radio-anatomic measurements and statistical generation of a safe surgical corridor to enter the ventricular trigone while avoiding injury to the optic radiations.

OBJECTIVE: To find a safe operative corridor to the ventricular trigone avoiding injury to the optic radiations (ORs). METHODS: In 24 adult hemispheres, dimensions of the atrium, height of the OR, and the cortex-to-atrium distance were measured. Superior parietal lobule (SPL), parieto-occipital sulcus (POS), and middle temporal gyrus (MTG) traced approaches were used to measure maximum safe angles to enter the atrium without traversing the OR. A statistical algorithm was generated using these measurements to predict the height of the OR and safe angles from measurements from MR imaging of five test hemispheres. Statistically calculated angles were compared with measured angles from dissection. RESULTS: Mean length and height of atrium, height of OR, and cortico-atrium distances were 2.07 cm, 3.36 cm, 2.53 cm, and 4.11 cm, respectively. The height of the atrium influenced the height of the OR significantly (p < 0.0001). The height of the dilated and small atrium was > 4.5 cm (> 95th percentile) and < 2 cm (< 5th percentile), respectively. For the SPL approach, the mean sagittal angle was 15.75 to 41.04 degrees; the mean coronal angle was - 17.08 to 14.92 degrees. For the POS approach, the mean sagittal angle was 51.29 to 70.1 degrees; the mean coronal angle was -8.63 to 17.22 degrees. Mean calculated height (statistically) of the OR was 0.29 mm above the mean observed height (dissection). The calculated angles and observed angles were very similar when tested for a variability of ± 2 degrees. CONCLUSION: The height of the normal atrium was 2.58 cm (height of atrium to height of OR ratio was 1:0.76). An operative corridor to the atrium without damaging the OR can be calculated from MR imaging of the brain.

Low-level amplification of oncogenes correlates inversely with age for patients with nontypical meningiomas.

BACKGROUND: This study sought to identify genes in nontypical meningiomas with gains in copy number (CN) that correlate with earlier age of onset, an indicator of aggressiveness. METHODS: Among 94 adult patients, 91 had 105 meningiomas that were histologically confirmed. World Health Organization grades I (typical), II (atypical), and III (anaplastic) were assigned to tumors in 76, 14, and 1 patient, respectively. Brain invasion indicated that two World Health Organization grade I meningiomas were biologically atypical. DNA from 15 invasive/atypical/anaplastic meningiomas and commercial normal DNA were analyzed with multiplex ligation dependent probe amplification. The CN ratios (fold differences from normal) for 78 genes were determined. The CN ratio was defined as [tumor CN]/[normal CN] for each gene to normalize results. RESULTS: Characteristic gene losses (CN ratio < 0.75) occurred in >50% of the invasive/atypical/anaplastic meningiomas at 22q11, 1p34.2, and 1p22.1 loci. Gains (CN ratio ≥ 2.0) occurred in each tumor for 2 or more of 19 genes. Each of the 19 genes' CN ratio was ≥ 2.0 in multiple tumors, and their collective sums (up to 49.1) correlated inversely with age (r = -0.72), minus an outlier. In patients ≤ 55 versus >55 years, 5 genes (BIRC2, BRAF, MET, NRAS, and PIK3CA) individually exhibited significantly higher CN ratios (P < 0.05) or a trend for them (P < 0.09), with corrections for multiple comparisons, and their sums correlated inversely with age (r = -0.74). CONCLUSIONS: Low levels of amplification for selected oncogenes in invasive/atypical/anaplastic meningiomas were higher in younger adults, with the CN gains potentially underlying biological aggressiveness associated with early tumor development.

Outcomes of mild to moderate upper eyelid ptosis correction using Müller's muscle-conjunctival resection.

BACKGROUND: Müller's muscle-conjunctival resection is used to correct mild to moderate ptosis commonly encountered in the rejuvenation patient population. The authors examined its efficacy and analyzed variables that potentially affect outcomes. METHODS: Patients who underwent ptosis correction using Müller's muscle-conjunctival resection with greater than 10-month follow-up were included. Amount of ptosis reduction, eyelid symmetry, effects of concomitant facial aesthetic operations, and adverse outcomes were analyzed. Patients were grouped into medium- (<24 months after surgery) and long-term follow-up (>24 months) cohorts to determine whether outcomes changed over time. RESULTS: Forty patients with a mean follow-up of 28 months combined for a total of 70 resection operations. Resection significantly reduced ptosis by a mean of 1.48 ± 0.88 mm (p < 0.001), corresponding to 0.19 mm of eyelid elevation for every 1.0 mm of Müller's muscle resected. The procedure successfully corrected 84 percent of eyelids to within 0.5 mm and 94 percent to within 1.0 mm of normal eyelid position. On patients with asymmetric ptosis, it significantly improved eyelid symmetry to within 1.0 mm from 85 percent of patients before surgery to 95 percent after surgery, and to within 0.5 mm from 53 percent before surgery to 75 percent of patients after surgery (p = 0.036). Furthermore, the mean correction of ptosis was not significantly different between medium- (1.58 ± 0.93 mm) and long-term (1.32 ± 0.93 mm) follow-up patients (p = 0.258). CONCLUSIONS: Müller's muscle-conjunctival resection is an effective long-term solution to mild to moderate eyelid ptosis and asymmetry, and can be effectively performed concomitantly with other aesthetic facial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Long-term follow-up of disability among patients with posterior inferior cerebellar artery aneurysm.

We retrospectively analyzed long-term follow-up data for 15 patients after treatment for posterior inferior cerebellar artery (PICA) aneurysm, particularly in relation to disability as assessed using the Modified Rankin Scale (MRS) score. Patients had a mean follow-up of 38 months. At follow-up, 53% of patients, those with an MRS score of 3, were able to lead an independent life, despite minor deficits. Patients with larger aneurysms may be more susceptible to lower cranial nerve palsies.