Initial Misidentification of Thumb Poroma by Shave Biopsy.

Poromas are benign adnexal neoplasms originating from the intraepidermal portion of sweat gland ducts. With the possibility of malignant transformation, accurate clinical diagnosis and treatment are crucial. Numerous reports of hand poroma lesions have been reported. We present an unusual case of a distal thumb poroma originally identified as a squamous cell lesion in a shave biopsy and eventually accurately identified after excisional biopsy. This report highlights the limitations of shave biopsy associated with soft tissue hand lesions and the need to consider poroma when evaluating a soft tissue lesion of the hand.

Oncologic reconstruction of the hand and upper extremity: Maximizing functional outcomes.

Upper extremity malignancies have the potential to create significant functional impairment, and as such represent an opportunity for collaborative reconstruction to minimize potential morbidity. Given the increased complexity and array of potential reconstruction solutions, functional limb preservation is overwhelmingly and increasingly successful in appropriately selected patients. The purpose of this review is to familiarize the reader with the general functional considerations of the upper extremity, review major reconstructive options, and present a general algorithm for reconstruction and maintenance of function. J. Surg. Oncol. 2016;113:946-954. © 2016 Wiley Periodicals, Inc.

Teleconferencing for Virtual Visiting Professors and Virtual Grand Rounds.

SUMMARY: The 2020 global pandemic related to the coronavirus has led to unprecedented interruptions in typical patient care and resident education. Teleconferencing software was deployed by many institutions to comply with quarantine and social-distancing regulations. To supplement the loss of clinical experience for trainees, the authors implemented a novel virtual-educational programming using virtual visiting professors and virtual grand rounds. The authors describe the two different formats and advantages such as access to multiple speakers on diverse, innovative topics and decreased financial burdens to the host program. However, the authors do acknowledge some disadvantages from lack of face-to-face social interaction/networking and the need to consider time-zone differences. Both new programs were embraced by trainees at the authors' own institution and residents/medical students across the United States and Canada and around the world. The authors believe teleconferencing should be permanently incorporated into future educational opportunities for plastic surgeons, as it provides easy access to high-quality information.

Carpometacarpal 4/5 Fracture Dislocations: Fracture Morphology and Surgical Treatment.

We conducted a retrospective review of six patients with carpometacarpal (CMC) ⅘ fracture-dislocations managed with ORIF by a single surgeon between October 2006 and August 2017. An open, dorsal approach to the hamate was used with a combination of interfragmentary screw fixation and Kirschner wire reduction in the CMC joints. At a mean of 96 days follow-up (range: 31-265), all patients had recovered wrist motion, excellent grip strength, and complete resolution of pain. There were no complications or reoperations during the postoperative period. Radiographic review showed restoration of anatomy and well-maintained congruity of the CMC joints. Our study has shown favorable outcomes after open reduction and internal fixation of the hamate body fracture with interfragmentary screws, when combined with stabilization of the CMC dislocation with percutaneous Kirschner wires. Fracture morphology does not appear to guide choice for specific hardware (size screw, headed/headless) or use of a washer. This is a level IV, therapeutic study.

Nerve Diameter in the Hand: A Cadaveric Study.

BACKGROUND: Nerve injuries in the hand are common and often pose a challenge for the upper extremity surgeon. A range of reconstructive options exist for nerve repair, but proper matching of nerve diameter is important for many of these techniques. The purposes of this study were to (1) describe the nerve diameters of the hand and their relative differences and (2) investigate whether there is a relationship between nerve diameter and external hand dimensions or body mass index. METHODS: We utilized 18 freshly frozen cadaveric hands from adult donors aged 20-86 of both sexes for this study. Two independent observers measured each nerve diameter to the nearest 0.1 mm using a digital caliper. RESULTS: Using the flexor zones as boundaries, a total of 33 nerve measurements were performed for each cadaveric hand. Nerve diameter increased from the distal to the proximal flexor zones. The internal common digital nerves in flexor zone 3 were larger than the external digital nerves. The median nerve was found to be nearly 2 times larger than the ulnar nerve at 2 locations within the wrist. There was a positive correlation between body mass index, hand span, hand width, and nerve diameter at several measured locations. CONCLUSIONS: This study provides reference values for nerve diameters of the hand and wrist and describes their relative differences. It is important for surgeons to be aware of these differences and to consider this information as we advance our efforts to reconstruct the hand and develop technologies for nerve repair.

Colo-colonic anastomosis in a continuous-flow left ventricular assist device patient.

Noncardiac operations are being increasingly performed on patients with left ventricular assist devices (LVADs). However, little is known on the impact of continuous-flow LVADs on the vascular supply of the colon for anastomoses. In this case, a 67-year-old male supported on an LVAD underwent four successful noncardiac operations including two intestinal anastomoses; left colon and small bowel anastomosis. To the best of our knowledge, no existing literature has reported successful colonic anastomosis on a continuous-flow LVAD. This case illustrates the plausibility of performing colonic anastomoses with appropriately selected patients supported on an LVAD. A 67-year-old male with congestive heart failure underwent LVAD placement for decompensated heart failure while awaiting orthotopic transplantation. During his recovery, he developed a stage IV sacral decubitus ulcer which required a sigmoid loop colostomy placement and a rotational flap. Subsequent stoma closure with partial sigmoid colectomy and stapled anastomosis was performed, and healed without evidence of anastomotic leak. This case illustrates the potential for colonic anastomoses for patients on continuous-flow LVAD support. Although oxygenation is known to be an important aspect of healing, this patient's outcome suggests that intestinal anastomoses can be performed on the induced pulseless environment of an LVAD. Further studies will be needed to further elucidate the success of longer segment resections and appropriate surgical candidates.

Breast Capsular Cerebrospinal Fluid Collection from Migration of a Ventriculoperitoneal Shunt Catheter.

In this case report we have described an unusual complication of ventriculoperitoneal shunt migration into a breast implant capsule. The patient was appropriately diagnosed with computed tomographic imaging and successfully managed with shunt revision and cerebrospinal fluid aspiration. Given the high complication profile of ventriculoperitoneal shunt catheters, this case suggests an opportunity for improved perioperative communication between plastic surgeons and neurosurgeons in patients with breast implants. Coordination regarding the subcutaneous catheter tunneling may hopefully minimize the risk of this complication.

Simplifying cheek reconstruction: a review of over 400 cases.

BACKGROUND: The cheek is a vast, well-vascularized facial subunit defined by the preauricular crease laterally, the mandible inferiorly, the lips and nasolabial fold medially, and the orbit-cheek crease and zygomatic arch superiorly. Reconstruction of the cheek commonly takes advantage of skin laxity in older patients and the relaxed skin tension lines of the face. Poor reconstructive techniques can cause or exacerbate significant deformities, especially in the oral and ocular regions. METHODS: Four hundred twenty-two cases of post-Mohs' cheek reconstruction were reviewed retrospectively. All cases were performed sequentially over 10 years by the senior author (J.F.T.). Indications, techniques, postoperative care, complications, and patient characteristics (e.g., age, sex, medical history, defect size, and skin quality) were taken into consideration for each case. RESULTS: The procedures used for cheek reconstruction included direct closure (53 percent), cervicofacial advancement flaps (19 percent), perialar crescentic advancement flaps (8 percent), full-thickness skin grafting (8 percent), V-Y advancement flaps (2 percent), and free flaps (1 percent). Although no attempt was made to modify patients' anticoagulation status before surgery, no hematomas were reported. Nine patients had multiple procedures for cancer recurrence or new defects, and all but four operations were performed at a university hospital outpatient surgery center. Seventeen total complications were noted from distal flap necrosis (n = 2), ectropion (n = 7), wound healing (n = 7), and compromised vascular supply (n = 1). CONCLUSION: Knowledge of aesthetic considerations and appropriate use of operative techniques yield optimum cheek reconstruction defined by successful wound closure, thoughtful scar placement, and minimal postoperative complications.

Total pancreatectomy: a national study.

BACKGROUND: Total pancreatectomy (TP) is performed for various indications. Historically, morbidity and mortality have been high. Recent series reporting improved peri-operative mortality have renewed interest in TP. We performed a national review of TP including indication, patient/hospital characteristics, complications and peri-operative mortality. METHODS: The Nationwide Inpatient Sample (NIS) was queried to identify TPs performed during 1998 to 2006. Univariate analyses were used to compare patient/hospital characteristics. Multivariable logistic regression was performed to identify predictors of in-hospital mortality. Post-operative complications/disposition were assessed. RESULTS: From 1998 to 2006, 4013 weighted patient-discharges occurred for TP. Fifty-three per cent were male; mean age 58 years. INDICATION: neoplastic disease 67.8%. Post-operative complications occurred in 28%. Univariate analyses: TPs increased significantly (1998, n = 384 vs. 2006 n = 494, P < 0.01). 77.1% of TPs occurred in teaching hospitals (P < 0.0001), 86.4% in hospitals performing or = 70 Adjusted odds ratio (AOR) 3.4, 95% confidence interval (CI) 1.33-8.67], select patient comorbidities and year (referent = 2004-2006; 1998-2000 AOR 2.70; 95% CI 1.41-5.14) independently predicted in-patient mortality whereas hospital surgical volume did not. DISCUSSION: TP is increasingly performed nationwide with a concomitant decrease in peri-operative mortality. Patient characteristics, rather than hospital volume, predicted increased mortality.