Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice.

BACKGROUND: Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS: We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS: US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION: Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.

Patient-reported satisfaction and quality of life after trans male gender affirming surgery.

Background: Trans male gender affirming surgery is becoming more available resulting in an increase in patients undergoing these procedures. There are few reports evaluating the outcomes of these procedures in the transgender population. This study was performed to provide patient-centric insight on self-image and other concerns that arise during surgical transition. Methods: A 22-question survey was sent to 680 trans male patients. The survey was broken down into the following sections: demographics, timing and type of surgical procedures, self-image, sex/dating life, social life, employment, co-existing psychiatric morbidity, and common issues faced during the surgical transition. Results: A total of 246 patients responded (36% response rate). Most patients (54%) waited 1-2 years after starting their transition before having a surgical procedure, and 10% waited longer than 6 years. In regard to self-image, sex/dating life, and social life there was a significant improvement (p < 0.001) after undergoing gender affirming surgery. Patients reported significantly less difficulty with employment after having gender affirming surgery (p < 0.001). If present, the following psychiatric morbidities were self-reported to have a statistically significant improvement after surgery: depression, anxiety, substance abuse, suicidal ideation, panic disorder, social phobia, and obsessive-compulsive disorder (P < 0.003). Conclusion: It is important to provide patients, surgeons, and insurance companies with expected outcomes of gender affirming surgery along with the potential risks and benefits. Post-surgical trans male patients reported a significant improvement in overall quality of life. Initial hesitations to having surgery such as regret and potential complications were found to be non-issues. Additional research should be done to include more patients with phalloplasties, trans females, and nonbinary identifying patients.

Longevity of Outcomes Following Reduction Mammoplasty.

Background: Reduction mammoplasty has been shown to provide wide-ranging benefits for patients including improved quality of life in terms of physical function and mental health. However, most existing studies have been limited to the 1-year postoperative period. The aim of this study was to investigate long-term outcomes after reduction mammoplasty. Methods: Patients who underwent reduction mammoplasty at a single institution were identified retrospectively and grouped into 3 categories based on time since surgery: (i) 5 to 10 years, (ii) 10 to 15 years, and (iii) more than 15 years. A telephone survey was administered to measure satisfaction and symptom relief following reduction mammoplasty. Results: A total of 124 patients completed the survey and were included in the study. The majority of patients in all 3 groups reported marked symptoms relief (75% vs 82% vs 82%, P = .84). Overall satisfaction after reduction mammoplasty was high in all 3 subgroups and did not significantly decrease over time (4.16 vs 3.97 vs 3.7, P = .216) despite high proportions of patients reporting an increase in breast size since surgery (40% vs 70% vs 51%, P = .0297). Conclusions: Overall, reduction mammoplasty has long-lasting benefits for patients with macromastia. Overwhelmingly, patients report satisfaction with the procedure and marked symptom relief that is sustained for as long as 15 years after surgery.

Postoperative Outcomes in Obese Patients That Undergo Ventral Hernia Repair versus Ventral Hernia Repair with Concurrent Panniculectomy.

BACKGROUND: The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone. METHODS: An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups. RESULTS: A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair-only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention. CONCLUSIONS: The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A large-volume academic center retrospective audit of the temporal evolution of immediate breast reconstruction protocols and the effect on breast prosthetic infection.

BACKGROUND: Complications of tissue expanders (TEs) in breast reconstruction are challenging. We sought to identify TE infection risks and acellular dermal matrix (ADM) and infection control protocol impacts on infection in a longitudinal study. METHODS: We retrospectively analyzed TE/implant reconstructions in 2004 (no ADM), 2009 (TE and ADM), 2013 (TE, ADM, and infection control protocol), and 2015 (TE, ADM, and infection control protocol). We assessed demographic, disease, and operative factors and analyzed rates of seroma, hematoma, skin necrosis, and infection. Statistical analysis, including simple and multivariable logistic regression, was performed using Stata v13.1. RESULTS: 478 TEs were placed in 324 women, with a 30% overall patient complication rate (23% of breasts). A total of 14% of TEs became infected. Although unadjusted analysis showed no ADM and infection association (p = 0.269), multivariable logistic regression showed a significant association with more infections (OR: 3.21; 95% CI: 1.13-9.313; p = 0.029). The infection control protocol decreased infections by 28% (16% in 2009 vs 11% in 2013); however, this did not achieve statistical significance (unadjusted p = 0.192, adjusted p = 0.156). Seroma (p < 0.001), older age (p = 0.040), larger mastectomy volume (p = 0.001), smoking (p = 0.037), BMI (p < 0.001), vascular disorders (p = 0.007), and hypertension (p < 0.001) significantly increased infections. CONCLUSIONS: Identifiable risks exist in TE/implant breast reconstruction. ADM infection risk may mitigate some potential benefits. Anti-infection protocols may reduce infections, and further investigation may reveal the most effective prophylactic strategies. Absence of major changes in complications over time supports validity of studies examining large numbers of despite evolution of techniques.

Utility of Postoperative Mandibulomaxillary Fixation After Rigid Internal Fixation of Isolated Mandibular Fractures.

PURPOSE: The utility of postoperative mandibulomaxillary fixation (MMF) after open reduction and internal fixation (ORIF) of mandible fractures is debated. The purpose of this study is to analyze if patients undergoing ORIF with postoperative MMF have improved outcome compared with those treated with ORIF alone. METHODS: A retrospective study was performed on patients who underwent ORIF of isolated mandibular fractures. Patients were divided into those placed in MMF postoperatively (ORIF with MMF) and those who were not (ORIF only). Postoperative complications and follow-up compliance were compared. RESULTS: A total of 238 patients were identified. Of these, 204 had sufficient follow-up with 94 patients in the ORIF with MMF group and 107 patients in the ORIF only group. Both groups had similar minor complication rates (13% vs 12%, P = 0.83) and major complication rates (16% vs 13%, P = 0.69). After adjusting for potential confounders, the use of postoperative MMF did not reduce the risk of minor (P = 0.34) or major complications (P = 0.57). Patients with postoperative MMF had a 5% lost to follow-up rate compared to 20% in the ORIF only group. CONCLUSION: Postoperative MMF does not improve clinical outcome after ORIF in patients with isolated mandible fractures but has the potential benefit of improving follow-up compliance.

Office-Based Three-Dimensional Printing Workflow for Craniomaxillofacial Fracture Repair.

Three-dimensional printing of patient-specific models is being used in various aspects of craniomaxillofacial reconstruction. Printing is typically outsourced to off-site vendors, with the main disadvantages being increased costs and time for production. Office-based 3-dimensional printing has been proposed as a means to reduce costs and delays, but remains largely underused because of the perception among surgeons that it is futuristic, highly technical, and prohibitively expensive. The goal of this report is to demonstrate the feasibility and ease of incorporating in-office 3-dimensional printing into the standard workflow for facial fracture repair.Patients with complex mandible fractures requiring open repair were identified. Open-source software was used to create virtual 3-dimensional skeletal models of the, initial injury pattern, and then the ideally reduced fractures based on preoperative computed tomography (CT) scan images. The virtual 3-dimensional skeletal models were then printed in our office using a commercially available 3-dimensional printer and bioplastic filament. The 3-dimensional skeletal models were used as templates to bend and shape titanium plates that were subsequently used for intraoperative fixation.Average print time was 6 hours. Excluding the 1-time cost of the 3-dimensional printer of $2500, roughly the cost of a single commercially produced model, the average material cost to print 1 model mandible was $4.30. Postoperative CT imaging demonstrated precise, predicted reduction in all patients.Office-based 3-dimensional printing of skeletal models can be routinely used in repair of facial fractures in an efficient and cost-effective manner.

Outcomes of Ventral Hernia Repair With Concomitant Panniculectomy.

PURPOSE: Combined ventral hernia repair and panniculectomy (VHR/PAN) is controversial, and the safety profile including anticipated complications has been questioned. We present a retrospective case series review of patients from the University of Maryland Medical Center to help surgeons counsel patients on the risks and benefits of this procedure. METHODS: A retrospective database was collected using current procedural terminology codes for VHR/PAN. The patient-specific variables that were studied include the following: sex, body mass index (BMI), smoking, diabetes, chronic obstructive pulmonary disease, cirrhosis, immunosuppression, length of operation, acute incarcerated hernias, hernia size and location, mesh size and location, pannus weight, concomitant component separation, use of negative-pressure wound therapy, intestinal violation, follow-up duration, ventral hernia working group, history of bariatric surgery, previous hernia repair, skin dehiscence, skin necrosis, chronic wound, surgical site infection, seroma, hematoma, fascial dehiscence, hernia recurrence, unplanned return to operating room, and medical complication. Both univariate and multivariate analyses were performed to determine which factors affected the complication outcomes. RESULTS: There were 106 patients with an average age and BMI of 53 years and 39, respectively. Fifty-eight patients (54.72%) had at least 1 surgical site occurrence. Twenty-three patients (21.70%) had at least 1 repair failure. Twenty-eight patients (26.42%) had an unplanned trip back to the operating room. Seventeen patients (16.04%) had at least 1 medical complication. CONCLUSIONS: The risk factors associated with developing complications are higher BMI, longer operating time, larger mesh size, larger hernia size, component separation, use of biologic mesh, chronic obstructive pulmonary disease, and intestinal violation. The use of negative-pressure wound therapy decreased complication rates, and patients with a previous hernia repair seemed to benefit the most from having a combined VHR/PAN. However, when compared with previous reports of VHR alone, VHR/PAN does seem to increase wound complications and reoperation rates.

Cosmetic Surgery Training in Plastic Surgery Residency Programs.

BACKGROUND: Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. METHODS: A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education-approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. RESULTS: Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. CONCLUSIONS: There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.

Antimicrobial Prophylaxis Practice Patterns in Breast Augmentation: A National Survey of Current Practice.

BACKGROUND: Breast augmentation is one of the most commonly performed aesthetic surgery procedures worldwide. Bacterial contamination is of paramount concern due to its role in biofilm formation and capsular contracture. Plastic surgeons have adopted a variety of perioperative interventions in efforts to reduce implant contamination, however definitive evidence supporting these practices is lacking. OBJECTIVE: The goal of this study was to assess current practice patterns aimed at reducing implant-related infections in breast augmentation and comparing them to current evidence-based medicine recommendations. METHODS: A 20-question survey assessing practices aimed at preventing breast implant associated infections was generated and distributed via SurveyMonkey to members of the American Society of Plastic Surgery whose electronic mail addresses were listed on the American Society of Plastic Surgery member website in April 2015. RESULTS: A total of 253 responses were received from the survey. Of the respondents, 81% were in private practice. Respondents averaged 21 ± 9 years in practice, and 69 ± 111 breast augmentations performed per year. A majority of surgeons used Chlorhexidine to prepare the surgical site (45%) and triple antibiotic solution both as a soak for the implant before placement (40%) as well as for implant pocket irrigation (47%). A no-touch technique using the Keller Funnel was adopted by 42% of surgeons. Regarding antibiotic use in the postoperative period, first-generation cephalosporins were used by the majority of respondents (79%), and the most common duration was for 4 to 6 days (45%). CONCLUSIONS: Although there is heterogeneity in specific aspects of antimicrobial prophylaxis during breast augmentation, there is a clear trend toward practice modification geared towards preventing bacterial contamination in breast augmentation. Surgeons may benefit from high-level studies designed to create standardized evidence-based practice guidelines.

Porcine Acellular Dermal Matrix for Hernia Repair in Transplant Patients.

PURPOSE: The purpose of this study was to compare clinical outcomes of incisional hernia repair in solid organ transplant patients using non-cross-linked porcine acellular dermal matrix (PADM), human derived acellular dermal matrix (HADM) and synthetic mesh. METHODS: A retrospective review of patients who underwent hernia repair with PADM after pancreas and/or renal transplant at the University of Maryland Medical Center from 2008 to 2012 was conducted. Repair type, postoperative infection, hernia recurrence, mesh removal, and length of follow-up were recorded. Results were compared with our previously published data evaluating HADM and synthetic mesh used in transplant patients between 2000 and 2005. RESULTS: Twenty-seven patients underwent ventral hernia repair with PADM, 34 patients were repaired with HADM and 26 were repaired with synthetic mesh. The rate of wound infection in those repaired with PADM, HADM, and synthetic mesh were 14.8%, 14.7%, and 65.4%, respectively. Rates of recurrence were 13.3%, 23.5%, and 76.9%, respectively. Rate of mesh removal was found to be 7.4%, 11.8%, and 69.2%, respectively. These complication rates were significantly lower in patients who received HADM or PADM compared with patients repaired with synthetic mesh (P < 0.001). There was no statistically significant difference in the outcomes between the groups repaired with HADM or PADM. CONCLUSIONS: The use of PADM for incisional hernia repair after kidney and/or pancreas transplant significantly reduces the incidence of hernia recurrence, wound infection, and need for mesh removal compared to synthetic mesh. No difference in morbidity between HADM and PADM was observed in the study population; however, longer follow-up in the PADM group is warranted.

Contemporary techniques for the correction of temporal hollowing: augmentation temporoplasty with the classic dermal fat graft.

INTRODUCTION: Temporal hollowing is a depression within the soft tissues overlying the temporal fossa, sometimes seen after surgical dissection for access to the facial skeleton. Surgeons have successfully used bone grafts, hydroxyapatite, methyl methacrylate, and autogenous tissue to correct the deformity. A systematic review of the literature demonstrated that the most popular technique for the correction of temporal hollowing seems to be the use of nonbiologic materials. These materials have been used successfully but are associated with some complications. There has been a growing experience with augmentation of the soft tissues of the temporal fossa using dermal fat grafts at our institutions, and this article describes this experience. METHODS: Two senior surgeons' recent experience with the correction of temporal hollowing was reviewed and analyzed. RESULTS: The retrospective review revealed 5 cases of temporal hollowing treated with dermal fat graft placement. Follow-up at 1 year revealed aesthetically pleasing results. CONCLUSIONS: A thorough understanding of temporal anatomy and conscious effort to respect structural integrity during dissection are essential in avoiding temporal hollowing. Sometimes, however, this deformity is impossible to avoid. In these patients, there are a number of options for correction. Open placement of the classic dermal fat graft is a technique that seems to offer good long-term aesthetic results.

A paradigm shift in correcting medial orbital fracture-related enophthalmos: volumetric augmentation through a lateral approach.

BACKGROUND: Posttraumatic enophthalmos resulting from medial orbital wall fractures presents a complex challenge. Access to this area through traditional incisions is limited, making visualization of the fracture site difficult. This can be ameliorated by the transcaruncular approach, but with the potential for complications both with access and with reconstructive materials. The authors sought a new technique where enophthalmos correction would be based on augmenting soft tissue volume, rather than reducing the volume of the bony orbital cone. This was successfully accomplished using porous high-density polyethylene wedges. In an effort to increase overall knowledge of this technique, a retrospective review was undertaken. METHODS: A retrospective chart review was undertaken to examine the senior authors' (J.F.T. and L.H.H.) experience using a lateral approach to address medial orbital fracture-related enophthalmos, aided by porous high-density polyethylene wedges to increase orbital volume. The relevant literature was reviewed and reported here. RESULTS: Three patients with post-medial orbital wall fracture enophthalmos were treated using a lateral approach to place porous high-density polyethylene wedges; this technique adequately corrected enophthalmos in these patients. CONCLUSIONS: Porous high-density polyethylene wedges can be placed into the orbit through a small lateral incision to reverse enophthalmos secondary to loss of volume after medial orbital wall fractures. Current techniques for orbital reconstruction typically focus on reduction of bony volume; this technique focuses on augmentation of soft tissue volume.

Optimizing pediatric interdental fixation by use of a paramedian palatal fixation site.

Condylar fractures are the most common injury seen in pediatric mandibular trauma. These injuries often cannot be adequately stabilized by conservative techniques such as splinting. The pediatric condyle fracture often requires a period of intermaxillary fixation. Because of the characteristics of the developing dentition, circumdental wiring is often not possible. Surgeons commonly achieve interdental stabilization by the connection of a circum-mandibular wire and a second wire placed through a drill hole in the piriform aperture. This method can be problematic in the young patient whose palatal suture is still patent. In this brief technical note, the use of a paramedian drill hole through the palate posterior to the maxillary incisors is described. It is believed that this method is superior to other techniques because it avoids injury to the deciduous tooth buds and allows for the maxillary wire to be seated in more structurally sound tissues.

Component separations.

Component separation is a technique used to provide adequate coverage for midline abdominal wall defects such as a large ventral hernia. This surgical technique is based on subcutaneous lateral dissection, fasciotomy lateral to the rectus abdominis muscle, and dissection on the plane between external and internal oblique muscles with medial advancement of the block that includes the rectus muscle and its fascia. This release allows for medial advancement of the fascia and closure of up to 20-cm wide defects in the midline area. Since its original description, components separation technique underwent multiple modifications with the ultimate goal to decrease the morbidity associated with the traditional procedure. The extensive subcutaneous lateral dissection had been associated with ischemia of the midline skin edges, wound dehiscence, infection, and seroma. Although the current trend is to proceed with minimally invasive component separation and to reinforce the fascia with mesh, the basic principles of the techniques as described by Ramirez et al in 1990 have not changed over the years. Surgeons who deal with the management of abdominal wall defects are highly encouraged to include this technique in their collection of treatment options.