Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes.

Background: Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. Methods: A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Results: Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. Conclusions: TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

Patient Characteristics and Spending Among Individuals Undergoing Ambulatory Panniculectomy and Abdominoplasty in the US from 2016 to 2019.

BACKGROUND: Abdominal contouring surgery can provide both functional and cosmetic benefits to patients with abdominal soft tissue laxity. Although these procedures have been studied in the inpatient setting, few studies describe abdominal contouring surgery in the ambulatory setting. OBJECTIVE: The purpose of this analysis was to investigate patterns in patient demographics between functional panniculectomy and cosmetic abdominoplasty using national data from the last four years. METHODS: Using the Nationwide Ambulatory Surgery Sample, we analyzed outpatient abdominal contouring procedures between 2016 and 2019. Encounters with a CPT 15830 were included. Procedures with ICD Z41.1 or CPT 15847 modifiers were defined as cases of cosmetic abdominoplasty. RESULTS: A weighted estimate of 95,289 encounters were included, with 66,531 (69.8%) functional panniculectomy and 28,758 (30.2%) cosmetic abdominoplasty procedures. Among patients with a history of bariatric surgery (23.8%; 95% CI, 22.3-25.4%), there was a 28.5% (4,866 in 2016 vs 6,254 in 2019) increase in panniculectomy and abdominoplasty. Compared with individuals who underwent cosmetic abdominoplasty, individuals who underwent functional panniculectomy were more racially diverse, had more comorbidities, and were more likely to be from low-income backgrounds. CONCLUSIONS: Rates of abdominal contouring surgery in the ambulatory setting have increased in recent years especially among individuals with previous bariatric surgery. There are important demographic and clinical differences between patients who underwent functional panniculectomy and cosmetic abdominoplasty including primary payer, comorbidities, and racial identity. LEVEL OF EVIDENCE III: 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 .

Delayed Versus Immediate Breast Reconstruction in the Ambulatory Surgery Setting: A Cross-Sectional Analysis of the Nationwide Ambulatory Surgery Sample.

BACKGROUND: Breast reconstruction remains an important part of a patient's journey after the diagnosis of breast carcinoma and treatment with mastectomy. Although inpatient immediate breast reconstruction has been described, there is a paucity information about whether similar procedures are performed in the ambulatory setting. OBJECTIVE: The authors sought to investigate rates and patterns for delayed and immediate breast reconstruction in the ambulatory surgery setting using nationally representative data from 2016 to 2019. METHODS: Using the Nationwide Ambulatory Surgery Sample database, we identified patients with an International Statistical Classification of Disease and Related Health Problems, Tenth Revision, procedure code for breast reconstruction. Demographic and clinical characteristics were recorded for each encounter of breast reconstruction, and linear regression and logistic regression were used to assess for trends and disparities. RESULTS: National weighted estimates for ambulatory breast reconstruction increased by 15.6% from 89 237 in 2016 to 103 134 in 2019, resulting in 377 109 procedures during the study period. Inflation-adjusted total charges for ambulatory breast reconstruction were $14 billion between 2016 and 2019, or 1.7% of overall charges for ambulatory surgery. Immediate reconstruction was performed in 34.7% (95% CI, 33.4%-36.1%) of cases and increased by 46.9% from 26 930 in 2016 to 39 559 in 2019. Racial disparities were observed in access, comorbidities, and spending. CONCLUSIONS: Our findings indicate a moderate increase in ambulatory breast reconstruction with a substantial growth in the performance of immediate breast reconstruction in the ambulatory setting.

Can Diffusion Tensor Imaging Apparent Diffusion Coefficient Diagnose Carpal Tunnel Syndrome? A Systematic Review and Meta-Analysis.

Magnetic resonance diffusion tensor imaging (DTI) can detect microstructural changes in peripheral nerves. Studies have reported that the median nerve apparent diffusion coefficient (ADC), a quantification of water molecule diffusion direction, is sensitive in diagnosing carpal tunnel syndrome (CTS). Five databases were searched for studies using ADC to investigate CTS. Apparent diffusion coefficient (measured in mm2/s) were pooled in random-effects meta-analyses. Twenty-two studies met criteria yielding 592 patients with CTS and 414 controls. Median nerve ADC were measured at the level of the distal radioulnar joint (CTS ADC: 1.11, 95% CI: 1.07-1.15, I2 = 54%; control ADC: 1.04, 95% CI: 1.01-1.07, I2 = 57%), pisiform (CTS ADC: 1.39, 95% CI: 1.37-1.42, I2 = 0%; control ADC: 1.27, 95% CI: 1.23-1.31, I2 = 59%), hamate (CTS ADC: 1.40, 95% CI: 1.36-1.43, I2 = 58%; control ADC: 1.27, 95% CI: 1.25-1.28, I2 = 47%), and as an combination of several measurements (CTS ADC: 1.40, 95% CI: 1.37-1.47, I2 = 100%; control ADC: 1.39, 95% CI: 1.24-1.53, I2 = 100%). Median nerve ADC is decreased in individuals with CTS compared to controls at the levels of the hamate and pisiform. ADC cut-offs to diagnose CTS should be established according to these anatomic levels and can be improved through additional studies that include use of a wrist coil.

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.

The Influence of Sagittal Head Tilt on Periorbital Appearance: Implications for Clinical Photography and the Evaluation of Postoperative Results.

BACKGROUND: Consistency in standardized periorbital photography-specifically, controlling for sagittal head tilt-is challenging yet critical for accurate assessment of preoperative and postoperative images. OBJECTIVES: To systematically assess differences in topographic measurements and perceived periorbital attractiveness at varying degrees of sagittal head tilt. METHODS: Standardized frontal photographs were obtained from 12 female volunteers (mean age 27.5 years) with the Frankfort plane between -15° and +15°. Unilateral periorbital areas were cropped, and topographic measurements were obtained. The images of each individual eye, at varying head tilt, were ranked in order of attractiveness by 11 blinded evaluators. RESULTS: Inter-rater and intra-rater reliability was excellent (intraclass correlation > 0.9). Downward sagittal head tilt was linearly associated with an improved aesthetic rating (Spearman's correlation; ρ = 0.901, P < 0.001). However, on subgroup analysis, eyes with lower lid bags received the highest aesthetic score at neutral head tilt. Pretarsal show and upper lid fold heights progressively decreased (P < 0.001), positive intercanthal tilt became more pronounced (P < 0.001), and the apex of the brow (P < 0.001) and lid crease (P = 0.036) arcs lateralized with downward sagittal head tilt, contributing to a more angular appearance of the eye. Marginal reflex distance (MRD) 1 was maintained, while MRD2 progressively increased (P < 0.001) with downward head tilt. CONCLUSIONS: Negative sagittal head tilt significantly improves periorbital aesthetics; however, in the presence of lower eyelid bags, this also increases demarcation of the eyelid cheek junction which may be aesthetically detrimental. Controlling for sagittal head tilt is critical to reliably compare preoperative and postoperative clinical photographs.

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study.

BACKGROUND: Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit. OBJECTIVES: The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA). METHODS: Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months. RESULTS: Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications. CONCLUSIONS: The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

Targeted Muscle Reinnervation at the Time of Upper-Extremity Amputation for the Treatment of Pain Severity and Symptoms.

PURPOSE: Targeted muscle reinnervation (TMR) is a technique for the management of peripheral nerves in amputation. Phantom limb pain (PLP) and residual limb pain (RLP) trouble many patients after amputation, and TMR has been shown to reduce this pain when performed after the initial amputation. We hypothesize that TMR at the time of amputation may improve pain for patients after major upper-extremity amputation. METHODS: We conducted a retrospective review of patients who underwent major upper-extremity amputation with TMR performed at the time of the index amputation (early TMR). Phantom limb pain and RLP intensity and associated symptoms were assessed using the numeric rating scale (NRS), the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity Short-Form 3a, the Pain Behavior Short-Form 7a, and the Pain Interference Short-Form 8a. The TMR cohort was compared with benchmarked data from a sample of upper-extremity amputees. RESULTS: Sixteen patients underwent early TMR and were compared with 55 benchmark patients. More than half of early TMR patients were without PLP (62%) compared with 24% of controls. Furthermore, half of all patients were free of RLP compared with 36% of controls. The median PROMIS PLP intensity score for the general sample was 47 versus 38 in the early TMR sample. Patients who underwent early TMR reported reduced pain behaviors and interference specific to PLP (50 vs 53 and 41 vs 50, respectively). The PROMIS RLP intensity score was lower in patients with early TMR (36 vs 47). CONCLUSIONS: This study demonstrates that early TMR is a promising strategy for treating pain and improving the quality of life in the upper-extremity amputee. Early TMR may preclude the need for additional surgery and represents an important technique for peripheral nerve surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Osseointegration of Extremity Prostheses: A Primer for the Plastic Surgeon.

Interest in amputation surgery has increased in conjunction with rising public awareness about amputee care. To date, plastic surgeons have impacted the quality of life and functional potential of amputees through novel strategies for sensory feedback and prosthesis control and various techniques for neuroma treatment and prevention. Osseointegration, which involves the direct skeletal attachment of a prosthesis to bone, has the ability to further maximize amputee function. There exists a critical role for plastic surgeons to help optimize techniques for extremity osseointegration through improved wound care and soft-tissue management. An overview of current osseointegrated prostheses and their associated limitations, and potential avenues through which plastic surgeons can help mitigate these challenges, are discussed in this article.

Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey.

More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain. METHODS: PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores (P < 0.05). RESULTS: Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 [interquartile range (IQR), 41-52] for RLP Intensity, 56.7 (IQR, 51-61) for RLP Behavior, and 55.9 (IQR, 41-63) for RLP Interference. Similar scores were calculated for PLP parameters: 46.8 (IQR, 41-54) for PLP Intensity, 56.2 (IQR, 50-61) for PLP Behavior, and 54.6 (IQR, 41-62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP. CONCLUSION: This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.

Getting Good Results in Cosmetic Blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately diagnose the cosmetic deformity and thoroughly understand the periorbital surface topography. 2. Develop a preoperative plan and pick the right operation. 3. Master technical tips. 4. Rejuvenate the lateral orbital area. 5. Manage complications. SUMMARY: Getting good results in blepharoplasty requires understanding ideal surface topography, accurate diagnosis of the cosmetic deformity, thorough knowledge of anatomy, and careful technique to change the anatomy. Several approaches have been described; however, the procedure continues to have its shortcomings and share of complications that have both functional and cosmetic consequences. This continuing medical education article focuses on getting good results and maximizing success in upper and lower blepharoplasty through the discussion of five major components: diagnosis and understanding of the cosmetic deformity; preoperative planning; technical tips; rejuvenation of the lateral orbital area; and management of complications.

Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.

BACKGROUND: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying. QUESTIONS/PURPOSES: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The Relationship between Animation Deformity and Patient-Reported Outcomes: Application of the BREAST-Q to a Quantitative Stratification of Animation Severity.

BACKGROUND: Animation deformity can occur following subpectoral breast reconstruction and is an oft-touted rationale for prepectoral reconstruction. Despite increasing recognition, there is a paucity of patient-reported outcome studies in women with animation deformity. METHODS: Women presenting after subpectoral implant-based breast reconstruction were evaluated for animation deformity. Video analysis and quantitative deformity assessment were performed in conjunction with BREAST-Q surveys. BREAST-Q data were compared to our quantitative animation grading scale to assess the relationship between animation severity and patient-reported outcomes. RESULTS: One hundred forty-one subpectoral breast reconstructions met inclusion criteria. Average scores were 67.8 ± 17.9 of 100 for satisfaction with breasts and 78.3 ± 14.1 of 100 for physical well-being. Animation deformity severity did not correlate with satisfaction with breasts (p = 0.44). Physical well-being, particularly pain-related questions, increased with increasing animation (p = 0.01); specifically, patients reported significantly less pulling, nagging, and aching in the breast (p = 0.01, p = 0.001, and p = 0.004, respectively). Patients with the least and most severe animation deformity had significantly higher numbers of revision procedures (0.89 and 1.03 procedures, respectively) compared with patients with intermediate deformity (0.49 procedures; p = 0.01 and p = 0.009, respectively). CONCLUSIONS: Although pectoralis release creates a more mobile-and more animating-reconstruction, this same release may lead to less pain because muscle is no longer contracting against a fixed space. This may lead to two distinct origins of subpectoral revision: (1) patients in pain (but low animation) and (2) patients with visibly distorted animation (but low pain). CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Histologic Analysis of Sensory and Motor Axons in Branches of the Human Brachial Plexus.

BACKGROUND: The topographic distribution through histologic analysis of motor and sensory axons within peripheral nerves at the brachial plexus level is not clearly defined, as there has previously been little need to appreciate this microanatomy. A desire to better understand the topography of fascicle groups developed with the introduction of targeted muscle reinnervation. METHODS: Fourteen bilateral brachial plexus specimens from seven fresh human cadavers were harvested at the time of organ donation, and immunofluorescent staining of motor and sensory nerves with choline acetyltransferase and Neurofilament 200 was performed to determine whether a consistent somatotopic orientation exists at the brachial plexus level. RESULTS: There was significant variability in the number of fascicles at the level of the brachial plexus. Qualitative analysis of choline acetyltransferase staining demonstrated that although motor axons tended to be grouped in clusters, there were high degrees of variability in somatotopic orientation across specimens. The radial nerve demonstrated the highest number of total myelinated axons, whereas the median nerve exhibited the greatest number of motor axons. The ulnar nerve contained only 13 percent motor axons, which was significantly lower than the median, radial, and musculocutaneous nerves. CONCLUSIONS: There was no consistent somatotopic organization of motor and sensory axons of the mixed major nerves of the arm just distal to the brachial plexus, but clustering of motor axons may facilitate the splitting of nerves into primarily "motor" and "sensory" fascicles.

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction.

BACKGROUND: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis. METHODS: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy. RESULTS: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84). CONCLUSIONS: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation.

BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain. STUDY DESIGN: A multi-institutional cohort study was conducted between 2012 and 2018. Fifty-one patients undergoing major limb amputation with immediate TMR were compared with 438 unselected major limb amputees. Primary outcomes included an 11-point Numerical Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behavior, and interference. RESULTS: Patients who underwent TMR had less PLP and residual limb pain compared with untreated amputee controls, across all subgroups and by all measures. Median "worst pain in the past 24 hours" for the TMR cohort was 1 out of 10 compared to 5 (PLP) and 4 (residual) out of 10 in the control population (p = 0.003 and p < 0.001, respectively). Median PROMIS t-scores were lower in TMR patients for both PLP (pain intensity [36.3 vs 48.3], pain behavior [50.1 vs 56.6], and pain interference [40.7 vs 55.8]) and residual limb pain (pain intensity [30.7 vs 46.8], pain behavior [36.7 vs 57.3], and pain interference [40.7 vs 57.3]). Targeted muscle reinnervation was associated with 3.03 (PLP) and 3.92 (residual) times higher odds of decreasing pain severity compared with general amputee participants. CONCLUSIONS: Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain.

Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model.

PURPOSE: Conventional suture repairs, when stressed, fail by suture rupture, knot slippage, or suture pull-through, when the suture cuts through the intervening tissue. The purpose of this study was to compare the biomechanical properties of flexor tendon repairs using a novel mesh suture with traditional suture repairs. METHODS: Sixty human cadaveric flexor digitorum profundus tendons were harvested and assigned to 1 of 3 suture repair groups: 3-0 and 4-0 braided poly-blend suture or 1-mm diameter mesh suture. All tendons were repaired using a 4-strand core cruciate suture configuration. Each tendon repair underwent linear loading or cyclic loading until failure. Outcome measures included yield strength, ultimate strength, the number of cycles and load required to achieve 1-mm and 2-mm gap formation, and failure. RESULTS: Mesh suture repairs had significantly higher yield and ultimate force values when compared with 3-0 and 4-0 braided poly-blend suture repairs under linear testing. The average force required to produce repair gaps was significantly higher in mesh suture repairs than in conventional suture. Mesh suture repairs endured a significantly greater number of cycles and force applied before failure compared with both 3-0 and 4-0 conventional suture. CONCLUSIONS: This ex vivo biomechanical study of flexor tendon repairs using a novel mesh suture reveals significant increases in average yield strength, ultimate strength, and average force required for gap formation and repair failure with mesh suture repairs compared with conventional sutures. CLINICAL RELEVANCE: Mesh suture-based flexor tendon repairs could lead to improved healing at earlier time points. The findings could allow for earlier mobilization, decreased adhesion formation, and lower rupture rates after flexor tendon repairs.

Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.

OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.