Association between patient-surgeon race and gender concordance and patient-reported outcomes following breast cancer surgery.

PURPOSE: Surgeon- and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between patient-surgeon race and gender concordance with QoL after breast reconstruction. METHODS: We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no, intermediate, and perfect concordance. Multivariable regression was used to correlate postoperative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender and race concordance. RESULTS: We identified 375 patients with a mean (± SD) age of 57.6 ± 11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender-discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (ß, 2.60; 95% CI, 0.21-4.99, p = 0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (ß, 2.14; 95% CI, 0.50-4.22, p = 0.045) than the race-discordant group. There were no significant associations observed between race or gender concordance and BREAST-Q performance. CONCLUSION: Race-concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery.

BACKGROUND: Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes. METHODS: A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation). RESULTS: A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m2, median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups. CONCLUSIONS: Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Acellular Dermal Matrix Provides Durable Long-Term Outcomes in Abdominal Wall Reconstruction: A Study of Patients with Over 60 Months of Follow-up.

BACKGROUND: Ventral hernia repair (VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce. OBJECTIVE: We sought to determine the rates of hernia recurrence (HR) and surgical site occurrences (SSOs) in a large cohort of patients who underwent AWR with biologic mesh. METHODS: We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM (PADM) or bovine ADM (BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up (LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs. RESULTS: We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m 2 . Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm 2 , mean mesh size was 414 ± 203 cm 2 . Hernia recurred in 93 patients (13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR ( P = 0.83) and SSO ( P = 0.87) between the 2 mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR. CONCLUSIONS: Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates.

Surgical and Ophthalmologic Outcomes of Reconstruction in Patients Treated With Eye-Sparing Surgery and Radiation Therapy for Tumors of the Lacrimal Drainage Apparatus.

INTRODUCTION: Tumors involving the lacrimal drainage apparatus can be effectively treated with oncologic eye-sparing resection, immediate reconstruction, and adjuvant radiation. The extirpative technique is well described, whereas the reconstructive approach and outcomes are limited and largely anecdotal. The present study describes the largest series in the literature evaluating outcomes after reconstruction after globe-preserving oncologic resection. METHODS: A retrospective review was performed for all patients undergoing reconstruction after resection of lacrimal gland tumors from 2008 to 2019. Reconstruction and ophthalmologic outcomes were assessed. RESULTS: Of the 17 patients included, 2 underwent complex repair, 6 were reconstructed with a locoregional flap, and 9 underwent free flap reconstruction. All patients were treated with adjuvant radiation therapy. The median follow-up was 19 months (range, 5-126 months). Defects reconstructed with free flaps had lower rates of wound dehiscence and fistula formation compared with those reconstructed with other techniques (11% vs 25%, P = 0.45). Patients undergoing reconstruction with free tissue transfer also tended to have lower rates of ectropion, keratopathy and decreased visual acuity compared with those undergoing nonmicrosurgical reconstruction (33% vs 50%, P = 0.48; 11% vs 38%, P = 0.20; 56% vs 75%, P = 0.40, respectively). These differences were not statistically significant. CONCLUSIONS: This is the first study to compare reconstructive and functional outcomes of nonmicrosurgical reconstruction and microsurgical free tissue transfer in the setting of eye-sparing surgery for tumors of the lacrimal drainage apparatus. Although various reconstructive options are feasible, microsurgical free tissue transfer is often used at our center and is associated with reliable outcomes.

Desmoplastic Melanoma of the Periorbital Region.

Desmoplastic melanoma (DM) is a rare subtype of melanoma and an even smaller proportion of periocular melanomas. Here, the authors report 2 cases of DM in the periocular region. Staged according to the American Joint Committee on Cancer (AJCC) eighth edition classification, patient 1 presented with a stage IIIC (pT4apN1cM0) DM in the left lateral canthus with upper and lower eyelid and patient 2 presented with a stage IIIB (T4aN1bM0) DM in the left brow and supraorbital region with a parotid lymph node metastasis. In both patients, the lesions were amelanotic, with inflammatory appearance, and had been noted for several years before the correct diagnosis was made. In both patients, wide excision led to large surgical defects, and perineural invasion prompted adjuvant radiation therapy postoperatively. Patient 2 was treated with an immune checkpoint inhibitor for his parotid metastasis. Ophthalmologists should be aware of DM, its neurotrophic nature, and potential to metastasize with locally advanced lesions.

Comparative study of caudal clonidine and midazolam added to bupivacaine during infra-umbilical surgeries in children.

BACKGROUND AND AIMS: Caudal analgesia is a good, reliable, and easy method to provide intraoperative and postoperative analgesia for infra-umbilical surgeries in children. Many additives are being used in combination with local anesthetics in caudal block to prolong the postoperative analgesia (clonidine, midazolam, ketamine, fentanyl, and dexmedetomidine). The purpose of this study was to compare the intraoperative hemodynamics, postoperative analgesia, postoperative rescue analgesic requirement, postoperative sedation and side-effects of clonidine and midazolam used as adjuvants to bupivacaine for caudal analgesia. MATERIAL AND METHODS: Following approval from Institutional Ethical Research Committee, 75 American Society of Anesthesiologists I and II patients aged between 1 and 7 years undergoing various elective infra-umbilical surgical procedures were included in this study. The patients were randomly allocated into three groups of 25 patients each. Group B received 1 ml/kg 0.25% bupivacaine in normal saline, Group BC received 1 ml/kg 0.25% bupivacaine + 1 µg/kg clonidine in normal saline, and Group BM received 1ml/kg 0.25% bupivacaine + 30 µg/kg midazolam in normal saline. The various parameters studied were intraoperative hemodynamic changes, duration of postoperative analgesia, postoperative sedation, postoperative analgesic requirement, and incidence of side-effects. RESULTS: All the groups were similar with respect to patient and block characteristics. The hemodynamic parameters before and after administering caudal analgesia were also comparable. The mean duration of analgesia was 724.80 ± 60.29 min in Group BC, 605.40 ± 82.37 min in Group BM and 295.00 ± 41.78 min in Group B. Thus, the duration of analgesia was significantly prolonged in Group BC compared to Groups BM and B. The FLACC pain score was higher in Group B at the end of 4th, 8th and 12th h compared with Group BC and Group BM. Furthermore at the end of 12th h, pain scores were significantly higher in Group BM compared to Group BC. Only 1 child in Group BC received three rescue medications compared to 15 (60%) children in Group B and 7 (28%) children in Group BM. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted. CONCLUSION: This study showed that the addition of both clonidine (1 µg/kg) and midazolam (30 µg/kg) with bupivacaine administered caudally significantly increase the duration of postoperative analgesia with minimal side-effects in children. The use of clonidine as an additive to bupivacaine in caudal epidural is a superior choice to midazolam as it reduces the demand of postoperative rescue analgesics significantly.

Free Fillet Flap of Lower Extremity: 38 Amputations with Seven Examples of Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces.

BACKGROUND: Extremely high-level lower extremity amputations are rare procedures that require significant soft-tissue and bony reconstruction. This study describes the use of fillet flaps for oncologic reconstruction and the incorporation of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs) for chronic pain prevention. METHODS: The authors performed a retrospective review of patients who underwent lower extremity fillet flaps at MD Anderson Cancer Center from January of 2004 through April of 2021. Surgical outcomes were summarized and compared. Numeric rating scale and patient-reported outcomes measures were collected. RESULTS: Thirty-eight fillet flaps were performed for lower extremity reconstruction. Extirpative surgery included external hemipelvectomy (42%), external hemipelvectomy with sacrectomy (32%), and supratrochanteric above-knee amputation (26%). Median defect size was 600 cm 2 , and 50% included a bony component. Twenty-one patients (55%) experienced postoperative complications, with 16 requiring operative intervention. There was an increased trend toward complications in patients with preoperative radiotherapy, although this was not significant (44% versus 65%; P = 0.203). Seven patients underwent TMR or RPNI. In these patients, the mean numeric rating scale residual limb pain score was 2.8 ± 3.4 ( n = 5; range, 0 to 4/10) and phantom limb pain was 4 ± 3.2 ( n = 6; range, 0 to 7/10). The mean Patient-Reported Outcomes Measures Information Systems T scores were as follows: pain intensity, 50.8 ± 10.6 ( n = 6; range, 30.7 to 60.5); pain interference, 59.2 ± 12.1 ( n = 5; range, 40.7 to 70.1); and pain behavior, 62.3 ± 6.7 ( n = 3; range, 54.6 to 67.2). CONCLUSIONS: Lower limb fillet flaps are reliable sources of bone, soft tissue, and nerve for reconstruction of oncologic amputation. TMR or RPNI are important new treatment adjuncts that should be considered during every amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. We aimed to evaluate outcomes of VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. METHODS: We conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January 2001 and March 2021. Our primary outcome measure included recipient and donor surgical site occurrences (SSOs). RESULTS: We identified a total of 546 patients (55% females) with a mean age was 58 years and mean BMI was 27 kg/m 2. Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient-site SSOs occurred in 38% of patients while donor-site SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients while bulge developed in 6.4% of patients. Cox proportional hazards regression model for hernia occurrence identified age, BMI, tobacco use (HR 2.03, 95% CI [1.02 - 4.04]) and use as an extended VRAM (HR 2.13, 95% CI [1.04 - 4.36]). The use of mesh or component separation were not independent protective factors for hernia occurrence. CONCLUSION: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor site hernia occurrence.

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series.

BACKGROUND: Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections. METHODS: A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed. RESULTS: Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent. CONCLUSION: The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Simple to Extreme: Following the Reconstructive Ladder for Complex Posterior Trunk Reconstruction.

Reconstruction of the posterior trunk and torso defects presents unique challenges to the reconstructive surgeon, particularly in the setting of oncologic resection and adjuvant multimodality therapy such as chemotherapy and radiation. The operation can be more complicated in the setting of hardware exposure. Although local flaps represent the primary workhorse option, reconstruction using a microvascular free tissue transfer should be considered when local flap options have been exhausted. Here, we present a unique case reconstructing a complex, radiated back wound with exposed hardware that failed prior bilateral paraspinous, latissimus dorsi, and trapezius muscle flaps. A unilateral free TRAM flap was used and revascularized through an arteriovenous loop to provide stable coverage of the 15 × 25 cm defect. The patient also had preexisting upper extremity ischemia, which limited flap perfusion and positioning options. The usage of arteriovenous loops and free musculocutaneous flaps can provide another potential adequate option for the treatment of these complex defects.

Autologous fat grafting in breast reconstruction: implications for follow-up and surveillance.

The procedural volume of autologous fat grafting (AFG) has risen over the past several years, specifically in the setting of breast reconstruction, despite controversy surrounding its oncologic safety. While some in vitro and animal models have cast doubt on the oncologic safety of AFG, there is no clinical evidence that AFG in breast reconstruction is associated with an increased risk of cancer development or recurrence or an inability to adequately assess changes in the breast. That being said, recommendations regarding surveillance and follow-up after AFG in breast reconstruction are largely surgeon directed and differ across practices. The purpose of this review is to summarize the current literature and provide evidence-based recommendations.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review.

BACKGROUND: The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario. METHODS: A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019. RESULTS: The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting. CONCLUSIONS: In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Understanding the Relationship between Breast Reconstruction Subtype and Risk of Financial Toxicity: A Single-Institution Pilot Study.

BACKGROUND: The impact of breast reconstruction on financial toxicity remains poorly understood despite growing awareness. The authors sought to illustrate the relationship between breast reconstruction subtypes and the risk of financial toxicity. METHODS: The authors conducted a single-institution cross-sectional survey of all female breast cancer patients undergoing any form of breast reconstruction between January of 2018 and June of 2019. Financial toxicity was measured by means of the validated Comprehensive Score for Financial Toxicity instrument. Demographics, clinical course, and coping strategies were abstracted from a purpose-built survey and electronic medical records. Multivariable linear regression was performed to identify associations with financial toxicity. RESULTS: The authors' analytical sample was 350 patients. One hundred eighty-four (52.6 percent) underwent oncoplastic reconstruction, 126 (36 percent) underwent implant-based reconstruction, and 40 (11.4 percent) underwent autologous reconstruction. Oncoplastic reconstruction recipients were older, had a higher body mass index, and were more likely to have supplemental insurance and receive adjuvant hormonal therapy. No significant differences in the risk of financial toxicity were uncovered across breast reconstruction subtypes (p = 0.53). Protective factors against financial toxicity were use of supplemental insurance (p = 0.0003) and escalating annual household income greater than $40,000 (p < 0.0001). Receipt of radiation therapy was positively associated with worsening financial toxicity (-2.69; 95 CI percent, -5.22 to -0.15). Financial coping strategies were prevalent across breast reconstruction subtypes. CONCLUSIONS: Breast reconstruction subtype does not differentially impact the risk of financial toxicity. Increasing income and supplemental insurance were found to be protective, whereas receipt of radiation therapy was positively associated with financial toxicity. Prospective, multicenter studies are needed to identify the main drivers of out-of-pocket costs and financial toxicity in breast cancer care.

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy.

BACKGROUND: Autologous fat grafting is a useful adjunct following breast reconstruction. The impact of autologous fat grafting on oncologic safety and surveillance remains questionable, particularly following breast conservation therapy. METHODS: The authors performed a retrospective review of patients who underwent delayed fat grafting following breast conservation therapy between 2006 and 2016. A control group of conservatively managed patients without grafting was matched for cancer stage, age, body mass index, and follow-up. Outcomes included locoregional recurrence and oncologic surveillance. RESULTS: Seventy-two patients were identified per cohort. There were no differences in median age (50 years versus 51 years; p = 0.87), body mass index (28.2 kg/m versus 27.2 kg/m; p = 0.38), or length of follow-up (61.9 months versus 66.8 months; p = 0.144) between controls and grafted patients, respectively. Overall, four patients in each cohort experienced recurrence (5.6 percent; p = 1.00) with similar cumulative incidence estimates observed (log-rank test, p = 0.534). There were no significant differences in palpable mass (9.7 percent versus 19.4 percent; p = 0.1), fat necrosis (34.7 percent versus 33.3 percent; p = 0.86), calcifications (37.5 percent versus 34.7 percent; p = 0.73), or indication for breast biopsy (15.3 percent versus 22.2 percent; p = 0.23) between breast conservation and breast conservation therapy plus autologous fat grafting cohorts, respectively. CONCLUSIONS: Overall, the authors found no difference in recurrence rates after breast conservation with or without delayed fat grafting. Furthermore, there were no differences in the rates of fat necrosis, palpable mass, and abnormal radiographic findings. This study represents the longest follow-up to date in in a large matched study of autologous fat grafting with breast conservation therapy demonstrating oncologic safety and no interference with follow-up surveillance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Surgical Outcomes in Lateral Abdominal Wall Reconstruction: A Comparative Analysis of Surgical Techniques.

BACKGROUND: Lateral abdominal wall (LAW) myofascial defects are a challenging reconstructive problem, and no consensus exists on their surgical management. We hypothesized that mesh repairs anchored to the nonyielding LAW boundaries (pillar-anchored repairs [PARs]) would provide more durable reconstructions, with lower hernia recurrence and bulge occurrence rates, compared with mesh repairs anchored to the surrounding oblique muscle complexes (direct repairs [DRs]). STUDY DESIGN: We retrospectively reviewed LAW reconstructions at a single center from 2004 to 2010. Patients were divided into 2 groups based on whether they had received a PAR or a DR. The primary outcome measure was hernia recurrence. The secondary outcome measures were surgical site occurrences (SSOs), surgical site infections (SSIs), and reoperations for complications. RESULTS: We analyzed 106 consecutive patients with LAW reconstructions (PAR, 59 DR, 47). The median follow-up time was 28.1 months (PAR, 24.5 months; DR, 34.5 months). The baseline demographics were similar in the groups. Nineteen hernia recurrences were observed (PAR, 5 [8.5%]; DR, 14 [29.8%]; p = 0.033, log-rank test). The "closure type" (bridged vs reinforced repair), "mesh type" or "defect area" were not associated with hernia recurrence or bulge occurrence. The groups did not differ significantly regarding SSOs, SSIs, or reoperations for complications. In the multivariable Cox proportional regression model, PAR provided a 3.5 times lower risk of hernia recurrence than DR (adjusted hazard ratio, 0.28; 95% CI 0.09 to 0.88; p = 0.03). CONCLUSIONS: The PAR technique is superior to DR for reconstructing LAW defects in order to achieve the lowest hernia recurrence rates in this complex patient population.

Lateral Abdominal Wall Reconstruction.

Lateral abdominal wall defects, while rare, present a more challenging problem than commonly encountered ventral defects due to the complexity of the anatomy, physiologic forces, and impact of muscle denervation. The lateral abdominal wall encompasses a large surface area ranging from the costal margin superiorly to the iliac crest inferiorly and from the linea semilunaris anteriorly to the paraspinous musculature posteriorly. The ratio of muscle to fascia/aponeurosis is much higher, which makes repair through muscle tissue versus fascia less secure. Furthermore, these defects are subject to asymmetric forces caused by the independent contraction of anterior and posterior muscle units, which lead to unbalanced strain and hernia progression. These features necessitate the use of wide underlay mesh load bearing repairs supported by the static pillars of the abdominal wall. Management can be further complicated when defects extend beyond the defined boundaries, requiring surgical repair to be adapted based on the border structures involved. Primary fascial coaptation may not be as easily accomplished, and therefore careful planning is important to ensure stable coverage of exposed mesh.

Neuroma Implantation into Long Bones: Clinical Foundation for a Novel Osseointegrated Peripheral Nerve Interface.

Symptomatic neuroma after major extremity amputation is a challenging clinical problem for which there are many described treatment options. Neuroma excision and implantation into the medullary canal of long bones offers durability and insulation, and minimizes chronic pain. Another challenge in amputees is impaired function and an ongoing need for accessible and functional prostheses that are "bidirectional," in that they provide both fine motor control and sensory feedback. Drawing on clinical experience with neuroma implantation into the medullary canal of long bones, the authors propose a novel neural interface whereby a terminal nerve end is redirected into the medullary canal of a nearby long bone and interfaced with an electrode array. The osseointegrated neural interface aims to exploit electrical signals from peripheral nerves to control advanced prosthetic devices for amputees. The purpose of this article is to present 2 clinical cases of nerve translocation into bone that serve as the clinical foundation of the osseointegrated neural interface as an innovative interface for prosthetic control.