PortFindr: A Novel, More Accurate, and Precise Device for Locating Tissue Expander Ports.

Two-stage breast reconstruction is the most common method of reconstructive modality following mastectomy and requires serial saline infusions into temporary tissue expanders through subcutaneous ports. Historically, these ports were located using a small magnet attached to a string or support structure. Magnetic force decreases exponentially as tissue thickness or fluid accumulation creates more distance between the TE port and skin. We developed a prototype handheld electronic device, the PortFindr, which more accurately and precisely locates the centre of subcutaneous ports. This device may lead to more confident localization of ports, less inadvertent puncture of tissue expanders, and thus less complications during infusions.

La reconstruction mammaire en deux étapes est la principale intervention reconstructive utilisée après une mastectomie. Elle exige plusieurs perfusions de soluté physiologique dans des expanseurs tissulaires temporaires par l'entremise de chambres sous-cutanées. Par le passé, ces chambres étaient localisées à l'aide d'un petit aimant fixé à une cordelette ou une structure de soutien. La force magnétique diminuait exponentiellement à mesure que l'épaisseur du tissu ou l'accumulation de liquide accroissait la distance entre la chambre et la peau. Les chercheurs ont créé un prototype électronique manuel, le PortFindr, qui situe le centre de la chambre sous-cutanée avec plus d'exactitude et de précision. Ce dispositif pourrait permettre de localiser les chambres de manière plus objective, de réduire les perforations accidentelles des expanseurs tissulaires et donc de limiter les complications pendant les perfusions.

Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training.

Reduced work hours and funding have fueled an increase in simulation-based training for plastic and orthopedic surgery residency programs. Unfortunately, certain simulation training can fail to enhance surgical skills because of availability, cost, or low fidelity. There is a growing interest among training programs for a cost-effective surgical simulator to improve basic skills and muscle memory of residents. The authors developed a three-dimensionally-printed, malleable, and anatomically accurate hand surgery simulator from a computed tomographic scan of an adult male subject. The bone matrix was specifically designed to provide proprioceptive feedback to hone drilling skills used in fracture repair and arthrodesis. The silicone soft-tissue covering provides excellent malleability to dissect and perform fracture-reducing maneuvers. Three-dimensional printing of "fracture bridges" allows the design of on-demand polyfracture models so the trainee can practice multiple types and locations of repairs as skills progress. To summarize, the authors' hand simulator is an anatomical, low-cost, multiprocedure tool that can be used to improve the muscle memory and basic surgery skills of residents in training.

Acquires Anterior Thoracic Lung Herniation and Repair: A Rare Case and Discussion.

We report a case of acquired anterior thoracic lung herniation in a 63-yeal-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.

IV 3000 Dressing for Fingertip Injury: Management and Discussion.

An active, right hand dominant. 86-year-old male presented with transverse amputation of the right ring finger just distal to the DIP joint. Conservative management was recommended in order to preserve digit length, mobility, and the DIP joint. The IV3000 semipermeable dressing was utilized as the primary treatment. The clear adhesive dressing has a high moisture vapor transmission rate that facilitates creation of a suitable wound microenvironment. The digit showed significant epithelialization and mobility at two weeks post-injury and was healed with full range of motion at both the DIP and PIP joints by week six. There were no complications from use of the IV3000 dressing, and both healing time and pain during dressing change are improved over alternative dressings like gauze.

Unilateral Forehead Paralysis Following Operative Repair of Facial Trauma: A Case Study and Review of the Literature.

The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery. We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.

Biomechanical analysis of the FlatWire Figure 8 sternal fixation device.

OBJECTIVE: To determine whether the FlatWire Figure 8 sternal fixation device (Penn United, USA) is mechanically superior to the current standard in sternotomy closure. DESCRIPTION: Unstable sternal closure using traditional steel-wire cerclage can increase postoperative pain, bony cut-through and wound dehiscence. The authors present the Figure 8 sternal fixation device to minimize these complications. Biomechanical properties of the device were compared with conventional steel wire sternal repair. EVALUATION: Using two constructs of both FlatWire and steel wire, pull-to-failure, Hertzian contact and cut-through were compared. Samples were tested to 500,000 cycles or failure. Cyclic comparisons were performed using log-rank t tests and Student's t tests for cut-through analysis. FlatWires were found to have superior biomechanical properties in all categories tested. CONCLUSION: The FlatWire provides superior biomechanical properties compared with conventional steel wire, which may lead to reduced sternal wound complications.

OBJECTIF: Déterminer si le dispositif de fixation du sternum FlatWire Figure 8 (Penn United, États-Unis) est mécaniquement supérieur à la norme actuelle pour la fermeture des sternotomies. DESCRIPTION: La fermeture du sternum au moyen du cerclage classique en fil d'acier peut accroître la douleur postopératoire, l'insertion osseuse et la déhiscence de la plaie. Les auteurs présentent le dispositif de fixation du sternum Figure 8 pour réduire ces complications au minimum. Les auteurs ont comparé les propriétés biomécaniques du dispositif à la réparation sternale classique à l'aide d'un fil d'acier. ÉVALUATION: Les auteurs ont comparé le test de tension, le contact hertzien et l'insertion du modèle FlatWire à celui du fil d'acier. Ils ont comparé les échantillons jusqu'à 500 000 cycles ou jusqu'à l'échec. Les comparaisons cycliques ont été effectuées au moyen de tests t de Mantel-Haenzel et de tests t pour l'analyse de tension. Le modèle FlatWire avait des propriétés biomécaniques supérieures dans toutes les catégories mises à l'essai. CONCLUSION: Le FlatWire a des propriétés biomécaniques supérieures à celles du fil d'acier classique, lesquelles peuvent réduire les complications de la plaie du sternum.

The lazy lateral incision: an innovative approach to the skin-sparing mastectomy.

The skin-sparing mastectomy has many advantages over a simple mastectomy, including preservation of the native breast skin, inframammary fold, and improved aesthetics for immediate reconstruction. The traditional transverse elliptical access incision is anterior on the breast mound, requires a second incision for previous biopsy sites, and provides restricted access to the axilla. We describe a novel mastectomy incision that improves scar appearance, improves access to the axillary contents, and reduces skin flap retraction. This incision starts at the nipple-areolar complex and extends laterally in a curvilinear fashion toward the axilla incorporating the biopsy scar along the way. This simple sinusoidal design results in an aesthetically superior alternative to the traditional linear mastectomy incision.

Eyelid reconstruction.

Reconstruction of the eyelids after excision of skin cancer can be challenging. Knowledge of surgical eyelid anatomy and appropriate preoperative planning are critical in order to perform eyelid reconstruction and minimize complications and the need for reoperation. The fundamental principle for full-thickness eyelid reconstruction is based on reconstructing the subunits of the eyelid, including the anterior and posterior lamellae as well as the tarsoligamentous sling.

Schwannoma of the ulnar nerve: a case report and review of the literature.

We report a case of a large ulnar nerve schwannoma, a rare type of soft tissue neoplasm. Diagnostic pearls are described to facilitate a more accurate and timely diagnosis. These characteristics include mobility, Tinel's sign, MRI target sign, S100 histological staining, Antoni patterns, and others. With a correct diagnosis, the tumor can be extirpated with preservation of nerve function and a low risk of recurrence.

Forehead reconstruction using a modified dual-plane A to T flap.

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces 'like with like'. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.

Les anomalies du front comportent de multiples défis pour le plasticien. Il existe de nombreuses possibilités pour reconstruire le front, de la fermeture primaire aux lambeaux libres. Pour optimiser l'agencement de couleur, de contour et de texture, la meilleure démarche consiste à utiliser des structures similaires. Lorsqu'il est impossible de procéder à une fermeture primaire en raison des dimensions, et que la couleur ou la profondeur ne se prêtent pas à une greffe, les lambeaux locorégionaux deviennent le pilier de la reconstruction. Les auteurs présentent trois cas dans lesquels un lambeau en A modifié en lambeau en T en deux plans est utilisé pour reconstruire les anomalies centrales et latérales du front d'une dimension pouvant atteindre 8 cm et ainsi obtenir d'excellents résultats esthétiques. Cette technique met en application les principes du lambeau périglabellaire, et les modifications sont conçues pour englober des anomalies plus importantes et les anomalies de la partie latérale du front.

Wendell L. Hughes' life and contributions to plastic surgery.

Wendell L. Hughes was a pioneer in ophthalmic plastic surgery and best known for the "Hughes flap," a tarsoconjunctival flap used for lower eyelid reconstruction. In 1937, Wendell L. Hughes sought to achieve the criterion standard of replacing "like with like" in his development of the tarsoconjunctival flap for lower lid reconstruction. This work was published in his ground-breaking thesis, Reconstructive Surgery of the Eyelids, the most comprehensive book on ophthalmic plastic surgery of its time. Although this flap has undergone many modifications, it has stood the test of time and is still used today. In addition, Dr. Hughes was heavily involved in surgical education, a founding member of the American Board of Plastic Surgery, and a leader in the development of sutures and microneedles. More importantly, he was a gracious humanitarian and inspiring mentor loved by peers and patients alike. Other authors have reviewed the intricacies of the Hughes flap; however, little attention has been given to the contributions of its creator.

A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods.

BACKGROUND: Flexor tendon repairs using conventional suture require knots that enlarge the cross-sectional area at the repair site. This enlargement increases the force of finger flexion and jeopardizes the integrity of a nascent tendon repair during rehabilitation. The authors hypothesized that a knotless flexor tendon repair using bidirectional barbed suture has similar strength and with reduced cross-sectional area compared with traditional techniques. METHODS: Sixty-six fresh porcine flexor digitorum profundus tendons were divided randomly into three groups. Tendons were transected and repaired with one of the following techniques: two-strand Kessler technique, four-strand Savage technique, or four-strand knotless technique. The cross-sectional area of each tendon was calculated at the repair site before and after repair. All tendons underwent mechanical testing to assess the 2-mm-gap formation force and ultimate strength. RESULTS: The 2-mm-gap formation force and ultimate strength of the Savage and knotless technique groups were not significantly different; however, both were significantly greater than those of the Kessler repair group (p<0.05). The repair-site cross-sectional area of tendons repaired with the knotless technique was significantly smaller than that of tendons repaired with the Kessler or Savage technique (p<0.01). Tendons repaired with the knotless technique also had a significantly smaller change in repair-site cross-sectional area (p<0.01). CONCLUSIONS: The authors demonstrate that knotless flexor tendon repair with barbed suture has equivalent strength and reduced repair-site cross-sectional area compared with traditional techniques. The smaller tendon profile may decrease gliding resistance, thus reducing the risk for postsurgical tendon rupture during rehabilitation.

The role of nerve transfers for C5-C6 brachial plexus injury in adults.

The brachial plexus consists of nerve roots C5-T1. Upper brachial plexus roots (C5-C6) innervate proximal muscles of the shoulder and upper arm. Injuries causing root avulsion or rupture require intensive treatment and significantly impact patients' quality of life. Nerves regenerate extremely slowly and without treatment, patients with upper brachial plexus lesions may lose motor function distal to the injury. Upper brachial plexus reconstruction using nerve transfers is a new method to bypass damaged areas thereby allowing patients to regain critical arm functions faster. We present a review of brachial plexus cadaveric anatomy, reconstruction transfer techniques, and management.

Free muscle flap reconstructions using interpositional vein grafts vs. local anastomosis: a 5-year experience at a rural tertiary care center.

BACKGROUND: The use of free muscle or myocutaneous flaps is well established as a means for reconstructing tissue defects over nearly any part of the body. This free tissue transfer is based on the availability of a robust blood supply in the recipient wound. The reliability of native blood supplies within the zone of injury is suspect even in the best of conditions. There are several causes of flap failure however; one of the most common is vascular compromise. Though refinements in the technique of vascular anastomosis have lessened the risk, it is still significant, especially when dealing with an area of injury at the recipient site. The mechanisms of scar formation and healing that occur within the zone of injury often limit the potential for viable anastomotic targets. This often leads to delay in wound coverage and exposes the patient to all of the risks associated with having an open wound. Free flap failure can be devastating for patients, even leading to the loss of limbs. Therefore, it is vital that all measures possible to ensure the survival of the transferred tissue be employed. METHODS: We will examine interpositional vein grafts versus local anastomoses in the context of free tissue transfer for wound coverage in the traumatized and reconstructed patient. We will retrospectively review the case histories of free tissue transfers preformed at West Virginia University Hospital over a 5-year period (2001-2006). We will examine data including the demographics of our patient population, type and locations of the free flaps, length of stay in the hospital, time interval between injury and repair, and the Success and failure rate. RESULTS: The overall success rate was 38 out of 45 or 84%. Success was defined as a healthy flap and preservation of the limb and/or successful wound coverage at time of discharge. Flap success was present in 18 of 23 (78%) of the vein interposition grafts, and flap failure occurred in 5 (22%). In patients with local anastomoses, 20 out of 22 flaps survived (91%) with 2 failures (9%). GOALS: We will demonstrate that the use of interpositional vein grafts for free tissue transfer is a viable option in the wound coverage. We will demonstrate that this is especially 'true in the patient population that exists in rural America.

Current concepts in breast reconstruction.

Breast cancer affects many women, but with advances in detection and treatment, survival rates have increased. Thus, it is important to understand that there are many reconstructive options available to help ease the psychological burden of mastectomy. Reconstructive options include tissue expander/implants, biologics, and several autologous tissue options, including pedicled latissimus and TRAM flaps, free TRAM flaps, and perforator flaps. We present a discussion of reconstructive techniques, the risks and benefits of each, and individual patient considerations that will help physicians to guide treatment options.

Lower eyelid reconstruction following Mohs surgery.

Lower eyelid defects resulting from Mohs micrographic surgery can be challenging to repair. These repairs are fraught with potential complication due to the lower eyelid's complex anatomy and defect variability. A single "cookie-cutter" treatment regimen does not exist because patients and defects vary. Surgical closure techniques include primary closure, eyelid advancement, rotational flaps, full thickness skin grafts, and/or allografts. We present a discussion of lower eyelid reconstruction including relevant anatomy, physical signs, and treatment options with examples.

The effect of cleft palate repair on contractile properties of single permeabilized muscle fibers from congenitally cleft goat palates.

Inherent differences in the levator veli palatini (LVP) muscle of cleft palates before palatoplasty may play a role in persistent postrepair velopharyngeal insufficiency (VPI). Contractile properties of LVP muscle fibers were analyzed from young (2-month) normal (YNP), young congenitally cleft (YCP) and again on the same YCP subjects 6 months after palatoplasty, mature repaired palate (MRP). The cross-sectional area and rate of force development (ktr) were measured. Specific force (sF(0)) and normalized power (nP(max)) were calculated. Using k(tr) to determine fiber type composition, YNP was 44% type 1 and 56% type 2, while YCP was 100% type 2. Two MRP subjects shifted to 100% type 1; 1 demonstrated increased resistance to fatigue. No differences in sF(0) were observed. nP(max) increased with presence of type 2 fibers. The persistent state of type 2 fibers following palatoplasty leads to increased fatigue in the LVP of MRP subjects and may cause VPI symptoms.