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Resume Introduction L’utilisation des medias sociaux a ete un bouleversement majeur de nos modes de vie dans la derniere decennie, A l’avant-garde dans la crise du lymphome anaplasique a grandes cellules lie aux implants mammaires -LAGC–AIM-, des fevrier 2019, notre centre universitaire a pris des mesures pour identifier et contacter toutes les patientes porteuses d’implants macro-textures. L’objectif de ce rappel etait d’informer les patientes sur les signes d’alerte et d’etablir une modalite de surveillance. Le but de ce travail est d’analyser les decisions des patientes suite a ce processus et de voir si la participation a un des groupes Facebook influencait cette prise de decision. Methodes Une etude retrospective de la cohorte de patientes, ayant demande et assiste a des rendez-vous avec un chirurgien, a ete faite. Le nombre de patientes presentant des signes cliniques d’alertes de LAGC–AIM, le nombre de patientes qui ont demande une intervention chirurgicale d’explantation de l’implant, les diagnostics histologiques retrouves apres la chirurgie ont ete colliges. Nous avons ensuite calcule la proportion de membres du groupe Facebook chez les patientes ayant exige une ablation d’implant en l’absence de diagnostic ou meme de signes d’alerte. Resultats Sept cent soixante-dix femmes ont demande un rendez-vous avec l’un des chirurgiens de notre service. De toutes les femmes qui ont demande une consultation, 497 (64,55 %) ont presente des symptomes. Seules 25 % des patientes, ayant consulte, avaient frequente un des groupes de patientes sur le reseau Facebook. Au terme de la consultation avec leur chirurgien, pres d’un quart des patientes ont un pris une decision d’ablation de l’implant contre l’avis medical. Parmi ces patientes, 67 % faisaient partie d’un groupe de patientes sur le reseau Facebook. A ce jour, aucun patient n’a recu de diagnostic de LAGC–AIM. Conclusions Ces resultats viennent supporter l’hypothese que l’appartenance a des groupes de patientes sur Facebook devient pour certaines un element cle du processus de decision.

Study Design Pilot randomized controlled trial with parallel groups. Introduction Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes. Purpose of the Study To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP). Methods Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery. Results Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η2 = .10), whereas an overall increased neurodynamics (P = .04, η2 = .11) and decreased pain severity (P = .01, η2 = .21) were observed. Discussion Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program’s content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended. Conclusion A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.

With surgical education moving from a time-based to a competency-based model, developing high-fidelity simulation models has become a priority. The Thiel cadaveric model has previously been used for a number of medical and surgical simulations, including microvascular simulation. We aim to investigate the use of the Thiel model in peripheral nerve simulation and validate a novel evaluation instrument. Sixteen residents ranging from postgraduate years 1 to 6 participated in the study. Their nerve coaptations using Thiel cadaveric nerves were video recorded and evaluated by 5 fellowship-trained microsurgeons using the Micro-Neurorrhaphy Evaluation Scale (MNES). The intraclass correlation among the 5 evaluators was 0.75, revealing excellent interrater reliability. The Cronbach α was .77, underlining the internal consistency of the test items. Bivariate analysis revealed a significant association between the MNES scores and the participants' self-declared level of experience. This correlation was confirmed by mixed modeling. Our results validate the MNES and underscore the utility of the Thiel nerve tissue for peripheral nerve surgical simulation.Puisque l’enseignement de la chirurgie passe d’un modèle axé sur le temps à un modèle axé sur les compétences, il est devenu prioritaire de créer des modèles de simulation haute fidélité. La méthode cadavérique de Thiel a déjà été utilisée pour plusieurs simulateurs médicaux et chirurgicaux, y compris la simulation microvasculaire. Les chercheurs ont l’intention de l’explorer pour la simulation des nerfs périphériques et de valider un nouvel instrument d’évaluation. Seize résidents de première à sixième année ont participé à l’étude. Leur coaptation nerveuse à l’aide des nerfs cadavériques de Thiel a été enregistrée sur vidéo et évaluée par cinq microchirurgiens possédant un postdoctorat à l’aide de l’échelle d’évaluation de la microneurorraphie (ÉÉMN). La corrélation intraclasse entre les cinq évaluateurs était de 0,75, révélant une excellente fiabilité interévaluateur. Le coefficient alpha de Cronbach était de 0,77, soulignant la cohérence interne des éléments à l’essai. L’analyse bivariée a révélé une association significative entre les scores d’ÉÉMN et le taux d’expérience déclaré par les participants. Cette corrélation a été confirmée par modélisation mixte. Les résultats des chercheurs valident l’ÉÉMN et soulignent l’utilité des tissus nerveux de Thiel pour la simulation chirurgicale des nerfs périphériques.

Frostbite causes tissue damage through five major mechanisms, out of which two are amenable to treatment. The first-line treatment is rapid rewarming therapy using water at 40°C to 42°C, which addresses the formation of ice crystals in the intra and extra cellular compartments. The second mechanism is progressive tissue ischemia after rewarming and is only accessible to a second-line therapy represented by thrombolysis. This study aimed to determine the efficacy of thrombolysis. This is a single-center retrospective cohort study, where it was aimed to evaluate two groups of patients. A total of 18 patients were included in this study. Mean times between injury to thrombolytic therapy and admission to thrombolytic therapy was 26.04 hours (SD 13.6) and 9.65 hours (SD 9.89), respectively. All patients suffered injuries ranging from second-degree deep to third degree. The rate of patients having complete, partial, and no angiographic responses were 55.6%, 11.1%, and 33.3%, respectively. The main outcome of interest showed that 11 (61.1%) patients in total had amputations at different levels. Results showed that in the intervention group, five (55.6%) of the patients had amputations compared with six (66.7%) from the control group (P = .6) at comparable levels of amputation. The literature supports that the use of intra-arterial tissue plasminogen activator might be beneficial for severe cases of frostbites; however, it lacks of studies of major significance and results are often controversial. Our study has not shown statistically significant results on amputation levels and cannot support the hypothesis of efficacy of thrombolytic therapy.

Background Although increasingly reported in the literature, most plastic surgeons cannot define the etiology of double capsules. Often an incidental finding at implant exchange, double capsules are frequently associated with macrotextured devices. Several mechanisms have been proposed, including at the forefront that shearing causes a delamination of the periprosthetic capsule into a double capsule. Objectives This study was designed to confirm the hypothesis that mechanical forces are involved in formation of double capsules by histological analysis. Methods A prospective analysis of consecutive implants with double capsules removed over 2 years was performed. Data collected at the time of surgery included Baker classification, reason for explant, implant manufacturer and style, and any presence of a seroma associated with the capsule. Specimens were sent for analysis by histology utilizing hematoxylin and eosin and alpha-smooth muscle actin staining techniques. Results Eight double capsules were collected for specimen analysis. All capsules demonstrated evidence of granulation tissue, alpha-smooth muscle actin positive myofibroblasts, and folds with embedded texture. Fibrosis surrounded weak areas with presence of layering and splitting, creating a potential space that is prone to separation. Tears and folds from granulomatous reaction are also present within the outer layer of the double capsule, which can only be explained by a mechanical shearing force as a pathogenic mechanism. Conclusions Understanding the pathogenesis of double capsules may allow plastic surgeons to refine their indications for macrotextured implants while providing guidance to patients on avoidance of activities that produce shear-forces. The findings support the hypothesis that shearing forces delaminate the capsule into 2 separate distinct capsules. Level of Evidence: 5

The Thiel embalmment method has recently been used in a number of medical simulation fields. The authors investigate the use of Thiel vessels as a high fidelity model for microvascular simulation and propose a new checklist-based evaluation instrument for microsurgical training.Thirteen residents and 2 attending microsurgeons performed video recorded microvascular anastomoses on Thiel embalmed arteries that were evaluated using a new evaluation instrument (Microvascular Evaluation Scale) by 4 fellowship trained microsurgeons. The internal validity was assessed using the Cronbach coefficient. The external validity was verified using regression models.The reliability assessment revealed an excellent intra-class correlation of 0.89. When comparing scores obtained by participants from different levels of training, attending surgeons and senior residents (Post Graduate Year [PGY] 4-5) scored significantly better than junior residents (PGY 1-3). The difference between senior residents and attending surgeons was not significant. When considering microsurgical experience, the differences were significant between the advanced group and the minimal and moderate experience groups. The differences between minimal and moderate experience groups were not significant. Based on the data obtained, a score of 8 would translate into a level of microsurgical competence appropriate for clinical microsurgery.Thiel cadaveric vessels are a high fidelity model for microsurgical simulation. Excellent internal and external validity measures were obtained using the Microvascular Evaluation Scale (MVES).La méthode d’embaumement Thiel a récemment été utilisée dans divers domaines de simulation médicale. Les auteurs explorent l’utilisation des vaisseaux Thiel comme modèle haute-fidélité pour la simulation microvasculaire et proposent un nouvel instrument d’évaluation de formation à la microchirurgie reposant sur une liste de vérification.Treize résidents et deux microchirurgiens traitants ont effectué des anastomoses microvasculaires sur des artères embaumées Thiel. Quatre microchirurgiens surspécialisés en ont évalué l’enregistrement à l’aide d’un nouvel instrument (échelle de simulation microchirurgicale en dix étapes). Ils ont évalué la validité interne au moyen du coefficient de Cronbach et vérifié la validité externe à l’aide de modèles de régression.L’évaluation de fiabilité a révélé une excellente corrélation intraclasse de 0,89. Lorsqu’on compare les scores obtenus par des participants de divers niveaux de formation, les chirurgiens et les résidents seniors (de quatrième ou cinquième année) ont obtenu des résultats significativement supérieurs à ceux des résidents juniors (de première à troisième année). La différence entre les résidents seniors et les chirurgiens traitants n’était pas significative. Les différences d’expérience microchirurgicale étaient significatives entre le groupe avancé et les groupes ayant une expérience minime ou modérée. D’après les données obtenues, un score de 8 désignerait un niveau de compétence microchirurgicale acceptable pour la microchirurgie clinique.Les vaisseaux cadavériques Thiel sont un modèle haute-fidélité de simulation microchirurgicale. D’excellentes mesures de validité interne et externe ont été obtenues au moyen de l’échelle de simulation microchirurgicale en dix étapes.

Summary Purpose Our aim is to do a comparative qualitative analysis of patents and “User Manuals” of the Biocell textured implants in order to determine if red flags were omitted when marketing and using Biocell textured implants. Materials and methods We performed a systematic qualitative analysis using the NVivo software version 11 of the patents describing the Biocell textured implants prior to their approval by the FDA and of user guides published by the 3 companies owning the patents (McGhan, Inamed, Allergan). To guide our thematic analysis, we used a form of systems theory known as the complexity theory. Results Four patents related to Biocell and 2 user manuals (McGhan- Inamed and Allergan) were analyzed. Four themes emerged from the patents: invention description, mechanism of action (Tissue ingrowth), the timing of the mechanism of action and hypothetical actions on capsular contractures prevention. Of all patent's content, 34% described the invention, 29% the mechanism of action (tissue ingrowth), 1% the timing of this mechanism of action and 34% a hypothetical action against capsular contracture. Solid evidence was found on the concept of anchoring and very little on capsular contracture. On the user guide side, the main themes were indications and contraindications, surgical techniques and long-term effects. The “directed” content analysis approach of the user guides regarding the patent's themes reflected that 94% of the user guides content related to the patent thematics was about the hypothetical role on capsular contracture while only 4% was about invention description and 1.5% about tissue ingrowth. Conclusions This analysis highlights the discrepancies between patents of Biocell textured implants and user guides for these implants. The indications of use of a treatment or device can evolve quicker than the study of its potential complications and side effects. The BIA-ALCL crisis should serve as a cautionary tale to the plastic surgery community which embraces new technologies eagerly, and sometimes precariously, in a mission to advance patient care.

Summary Background Simulation models are increasingly important for skill acquisition during microsurgery training. Prosthetics, living and non-living biological models have been proposed in the literature in the optics of recreating real-life scenarios in a controlled environment. This study aims to validate and prove the reusability of a novel non-living biological model: the porcine placenta. Methods A prospective comparative study was carried out to assess face and content validities of the proposed model, as well as the reusability and quality of the Thiel-embalming method. Participants were asked answer a questionnaire for each anastomosis they performed on porcine placental vessels of ≤ 2 mm (small) and 2–4 mm (large). Scores were classified according to different subgroups, either small or large vessels and first or second sessions. Reliability analysis of the questionnaire was carried out using Cronbach's α, to ensure an α > 0.7. Median scores for each question were analyzed using boxplots and compared amongst each subgroup using a non-parametric independent Mann-Whitney U test. Results With nine participants, the Cronbach's α for each category of question was 0.867, 0.778, 0.720 and 0.593. Statistical differences were found between responses of small and large vessels on 5/10 questions, where large vessels reported higher validity. No statistical differences were found between scores of the first and second sessions. Conclusion By evaluating face and content validity, the Thiel-embalmed porcine placenta has proven its suitability as a microsurgery model, especially for vessels of larger caliber. Qualities that distinguish this model is its reliable reusability, its low cost-effectiveness, and its ethical acceptability.

Summary Background The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. However, while estrogens play a crucial role in wound healing, no study has assessed the impact of tamoxifen or aromatase inhibitors on other postoperative breast reconstruction complications, including infections, necrosis, capsular contracture and seroma. As breast cancer patients undergoing Implants-ADMs breast reconstruction are often receiving hormone therapy, it is unclear whether this increased infection risk is associated with increased infections cases. Methods A prospective study was performed on patients undergoing breast reconstruction at an academic institution from 2013 to 2016. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including infections, necrosis, seroma and hematomas, were compared and analyzed using univariate and logistic regression models. Results Among a total of 112 patients (183breasts), 58 patients (91 breasts) were receiving hormone therapy and 54 patients (92 breasts) were not. The hormone therapy group had a higher incidence of postoperative mastectomy skin infection (20.7% versus 7.4%; P = 0.0447), we didn’t find any significant differences in necrosis. Conclusions Hormone therapy was associated with a higher incidence of Infections after breast reconstruction with ADMs and implants. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors. Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: does hormone therapy increases the risk of infection?

Background Skin coverage remains a significant hurdle in large-sized burns. Recent advances have allowed to grow Bilaminar Cultured Skin Autografts (BCSGs) from patients’ own donor sites. The aim of this study was to report long-term outcomes in patients with large-sized burns having received BCSGs. Methods Nine patients received BCSGs from January 2010 to May 2015. Except one patient who died during hospitalization, all patients were contacted. Four agreed to partake in the study. Patients were tested with the Vancouver Scar Scale (VSS), QuickDASH questionnaire and Burn Specific Health Scale (BSHS). Incisional biopsies of BCSGs were compared with patients’ autografts. Results From nine patients, mean age was 40 years and mean TBSA was 70.3%. For the four patients included, score averaged was 2.25 on the VSS, 29.5 on QuickDASH, 36/36 for psychosocial items and 63/84 for functional abilities on the BSHS. Compared with autografts, BCSGs demonstrated better pliability VSS and functionality. Biopsies showed no evidence of malignancy or atypical changes, but areas of hyperpigmentation. Conclusion This is the first report investigating the long-term outcome of a newly developed BCSG. BCSGs demonstrated comparable results with patients’ autografts, functional outcomes on self-reported questionnaires and excellent psychological states. Precaution given the extensive unexpected hyperpigmentation must be taken and a randomized controlled study is underway.

Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix- and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors' institution. During surgery, 1-cm specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use-based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix-based reconstructions are salvaged, this could come at the price of chronic local inflammation.

Background After thumb amputations, restoration of function and aesthetic can be accomplished with microvascular free toe flaps. However, many patients in clinical practice do not choose this reconstruction despite positive reported outcomes. This study aims to determine patients' perceptions with respect to free toe flaps to improve areas of informed consent. Methods A retrospective survey was administered to patients with thumb amputations. Participants were required to complete a questionnaire about patient demographics, the Brief Michigan Hand Questionnaire (bMHQ), the standard gamble/time trade-off questionnaires for utility scores, and a questionnaire investigating potential reasons for electing not to undergo a free toe transfer. Results Thirty patients were enrolled in the study wherein 53% underwent a replantation procedure, 27% a revision amputation, and 20% a delayed reconstruction. Mean normalized score on the bMHQ was recorded as 63.54. Utility questionnaires yielded mean measures of 0.8967 and 0.86 on the standard gamble and time trade-off, respectively. From 14 elements, a majority (87%) stated flap failure as a major source of concern, followed by lack of understanding of risks and benefits (80%) and prolonged hospital stay (53%). Cultural/religious beliefs, aesthetic appearance of the foot, and concerns about footwear were not reported as important reasons in 90, 80, and 79% of patients, respectively. Conclusion A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address their concerns during informed consent. This study emphasizes the importance to discuss about failure rates, risks, and benefits of the operation and prolonged hospital stay.

Background Despite benefits in reducing capsular contractures, textured implants have been associated with significant pitfalls, such a propensity for biofilm formation. Few studies have investigated whether the use of acellular dermal matrix on textured implants produces similar findings. This study aims to characterize biofilm formation at the capsular-acellular dermal matrix interface with scanning electron microscopy. Methods The authors performed a prospective observational pilot study in patients undergoing two-stage expander-to-permanent implant exchange. Patients were inflated with Biocell or Siltex expanders, and specimens from the capsular-pectoralis interface and capsular-acellular dermal matrix interface were obtained and examined under scanning electron microscopy for capsular ingrowth and biofilm formation using the Van Herdeen Biofilm Grading System and the Biofilm Thickness Grading Scale. Results Nine patients including 14 breasts (28 capsular samples in total) were examined. Thick biofilm formation was observed in all specimens from the capsular-acellular dermal matrix interface with Biocell and 25 percent of capsule-pectoralis interface, whereas no biofilm formation was found in Siltex implants. For Biocell implants, a significant difference in biofilm coverage between the upper and lower poles was observed using the Van Herdeen Biofilm Grading System (p = 0.0028) and the Biofilm Thickness Grading Scale (p = 0.0161). Conclusions Biocell implants produce a significant rate of biofilm formation over acellular dermal matrix-covered capsules, which is not present in the muscular region or in Siltex implants. Further randomized controlled trials will further elucidate the clinical impact of using acellular dermal matrices with macrotextured implants. Clinical question/level of evidence Therapeutic, IV.

Background To prevent postoperative thrombosis, indications for anticoagulation in finger replantation have been described, but no consensus has yet been found for cessation protocols. The aim of this study is to investigate cessation methods of intravenous anticoagulation after finger replantation. Methods A retrospective review of all patients treated for a finger replantation between December 2014 and July 2016 was performed. Only those who required postoperative treatment with intravenous heparin were extracted. Primary outcome was survival of finger at hospital discharge and data collection focused on postoperative anticoagulation regimens. Results 108 patients with replantation were treated with intravenous heparin and included in the analysis. When anticoagulated, survival rate was 60% (n = 65) at hospital discharge, wherein arterial and venous thrombosis accounted for 60 and 40% respectively. Descriptive analysis failed to demonstrate an increase in failure rates when tested for duration of intravenous heparin, fixed or variable infusion rates of anticoagulation and need for vascular grafts. However, there was a 2.8-fold (P = .009) increase in the survival rate with progressive weaning of anticoagulation rather than abrupt discontinuation. Subgroup analysis demonstrated similar findings when considering arterial thrombosis alone (OR 5.2, P = .012), but did not show any significant difference for venous thrombosis (OR 1.7, P = .344). Conclusions Progressive tapering of intravenous heparin is associated with an increased survival rate after finger replantation, particularly for arterial thrombosis. Further prospective and randomized trials are necessary to elucidate the optimal duration, method of infusion and indications for vascular grafts.

Summary Background Macro-texturing of breast implants was developed with the double goal of improving implant stabilization within the breast cavity and decreasing the rate of capsular contractures. However, recent evidence suggests that double capsular formation, a potentially worrisome phenomenon associated with late seromas and biofilms, occurs with preponderance in macro-textured implants. Our objective was to analyze histologically different regions of double capsules to determine if they are more prone to mechanical movements. Methods A prospective analysis including patients undergoing second-stage expander to definitive breast-implant reconstruction post-mastectomy was conducted after intraoperative identification of the double capsule phenomenon. Two samples were collected from each capsules around the implant, located centrally and laterally. The specimens were sent for histological analysis by the institution's pathologist. Results In total, 10 patients were identified intraoperatively with partial double capsule phenomenon. Among samples retrieved from the lateral aspect of the breast implant, all were associated with delamination and fractures in the collagen matrix of the double capsules. This phenomenon was not observed in any sample from the dome of the breast. Conclusions Breast-implant macro-texturing plays an important role on delamination of capsules on lateral portions of the breast, which may have an etiologic role in double capsule formation. Manufacturing implants with macro-texturing on one side and smooth surface on the other could diminish mechanical shear forces responsible for these findings.

Summary:. Pedicled latissimus dorsi musculocutaneous flaps are reliable options for reconstruction of torso and head and neck defects. After ensuring that no kink or external compression occurs on the pedicle, the survival rate exceeds 99%. However, we experienced a complete necrosis of the flap after insertion of a peripherally inserted central catheter line. Intraoperative findings demonstrated thrombosis of the subclavian vein over a large segment, which was found to be the cause of flap failure. The clinical significance of this case report is aimed at raising awareness against insertion of peripherally inserted central catheter lines on the ipsilateral arm of a pedicled latissimus dorsi flap.

Free flap reconstruction in acute burns has high failure rates, relating mainly to a systemic inflammatory state. The “vulnerable phase” can last for 6 weeks after burn and can cause thrombosis of the flap microcirculation with patent arterial and venous anastomoses. Revision surgery alone may be unsuccessful, but thrombolysis can lead to flap salvage. We describe a case of successful flap salvage with thrombolysis after unsuccessful revision surgery by permeable arterial and venous anastomoses in a patient in the acute burn phase suffering from microcirculatory thrombosis. Thrombolysis in these cases has not been described to date, but it could contribute to salvaging flaps by radiological intervention alone. A 23-year-old man was admitted with a 38% TBSA burn, including loss of all eyelid skin. The right eye was reconstructed in a satisfactory manner, but the left eye required urgent corneal coverage on day 32 with a dorsalis pedis fasciocutaneous free flap. The flap was hypo-perfused postoperatively, but anastomoses were found to be permeable on exploration. Angiography performed postoperatively after revision confirmed anastomotic patency, but failed to demonstrate small vessel beds within the flap. Thus, r-tPa was given at the anastomosis site and immediately the flap recovered completely. However, a total of 10 packed red blood cell transfusions were needed over the next 9 days. Thrombolysis in the context of free flap microvascular compromise may improve the overall success rates, especially in acute-phase burn patients where this etiology may be found, due to a vulnerable inflammatory period.

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal joint osteoarthritis may have both postoperative benefits and complications. This study sought to determine the health state utility outcome measures of trapeziectomy with LRTI. Patients who underwent trapeziectomy with LRTI were invited to complete the brief Michigan Hand Questionnaire and utility questionnaires outcomes using a visual analogue scale , time trade-off and standard gamble. Quality-adjusted life years (QALYs) were derived from these utility measures. For this study 32 patients were recruited, with a mean age of 61. Most patients (27/32) perceived the procedure as successful. Utility measures and QALYs serve the purpose of comparing different surgical procedures in terms of their impact on the quality of life of patients as a function of the benefits and complications of each procedure. In this study, the utility of trapeziectomy with LRTI was less than has been described for open palmar fasciectomy but more than for total wrist arthrodesis.Level of evidence: IV

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: "upper extremity," "arm," "forearm," "wrist," "hand," "finger" AND "negative-pressure wound therapy," "VAC therapy," "vacuum assisted closure." A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Background Sensory and motor disturbances are characteristic of musculoskeletal injuries and conditions. Rehabilitation interventions aimed at remediating these disturbances are traditionally exclusively targeted to the affected area. However, there is some evidence of bilateral changes in sensory and motor function associated with unilateral injuries and conditions suggesting central changes. Deficits on specific cognitive tasks have also been documented in persons with chronic pain. Purpose The purpose of the present study was to determine if participants with unilateral pain arising from heterogeneous wrist/hand injuries and conditions demonstrate bilateral changes in sensory and motor functions as well as cognitive deficits. Design/methods Sensory (Pressure Pain Thresholds, Two Point Orientation Discrimination), Motor (grip strength and Purdue Pegboard), and Cognitive function (Stroop test and mental rotation task) were measured in 30 participants with wrist/hand pain and 30 healthy control participants in an observational cross-sectional study. Results Participants with unilateral wrist/hand pain demonstrated differences in cognitive function measured with the Stroop test (p = 0.03). They also demonstrated bilateral sensorimotor differences in pressure pain thresholds (p = 0.03), grip strength (p = 0.00) and Purdue pegboard test (p = 0.03) results compared to healthy control participants. Conclusion Cognitive as well as bilateral alterations in sensory and motor function in participants with musculoskeletal injuries and conditions suggest central changes are involved in their pathophysiology. These findings in persons with heterogeneous injuries/conditions suggest that these changes are not specific to an injury/condition. Bilateral sensorimotor changes have important implications with regards to the pathophysiology of musculoskeletal disorders of the wrist/hand, for rehabilitative interventions and research.

Study Design Cross-sectional. Introduction Pain severity, sensory and motor impairment, and psychological (distress and anxiety) and social factors have previously been related to self-reported disability in persons with wrist and hand pain. Purpose of the study The purpose of this study to determine the relative contribution of pain severity, measures of impairment (sensory and motor function), psychosocial factors, and pain interference on self-reported disability experienced by persons with heterogeneous orthopedic injuries and conditions of the wrist and hand. Methods Measures of disability and pain severity as well as measures of sensory (pressure pain thresholds, joint position sense), motor (grip strength, Purdue pegboard), and cognitive performance (Stroop test) and psychosocial variables related to pain and participation (West Haven-Yale Multidimensional Pain Inventory) were administered to 60 participants with wrist and hand pain. Pearson product correlations controlled for age and sex, and multiple linear regression was performed to determine the relationship between measures of impairment, pain severity, psychosocial variables, and pain interference with self-reported disability assessed with the Disability of Arm, Shoulder and Hand (DASH) questionnaire. Results The best-fitting regression model with DASH scores entered as the dependent variable (F4,50 = 28.8, P Conclusion Pain interference appears to be an important factor explaining the link between impairment, pain severity, and self-reported disability. Addressing pain interference may be important to improve outcomes in this population.

Summary Introduction Despite positive outcomes reported in the literature, some surgeons remain reluctant to the systematic use of venous couplers in free flap tissue transfer. In our institution, the use of the coupler devices for venous anastomosis in free flap breast reconstruction has yet to be adopted by all surgeons. The purpose of the study was to compare postoperative outcomes of coupler-assisted venous anastomoses with hand-sewn techniques in free flap breast reconstruction. Methods An analysis of collected data was performed on cases of breast reconstruction with free tissue transfer after mastectomy in breast cancer or BRCA-positive patients from 2010 to 2016. Patients were divided into two groups: coupler device and hand-sewn. The primary outcome was survival rate of free flaps. Secondary outcomes included potential complications, as well as surgical characteristics (recipient artery/vein, coupler size, type of hand-sewn anastomosis, size of sutures, number of venous anastomoses, ischemia time, operative time) Results We included 289 cases in our study. There were no significant differences between groups in terms of post-operative complications or survival rate of the free flaps. Ischemia time was significantly lower in both immediate and delayed reconstruction cases. Operative and anesthesia times were significantly lower only in immediate unilateral cases. Conclusion Although ischemia time was reduced in the coupler group, we didn’t find any significant difference in the operative and anesthesia time in the subgroup analysis, except for the group of immediate unilateral breast reconstruction. Couplers are safe and efficient; nevertheless, our study shows that their qualities cannot yet justify the disappearance of the manual sutures.

Clinical approach to surgical patients has evolved to include previous patients as part of the treating team in the role of "patient-advisors". Knowing that compliance to rehabilitation protocols is significant for a successful functional hand replantation, we set out to quantify functional patient-reported outcomes in individuals enrolled in a Patient-Advisor Program (PAP). We performed a prospective cohort pilot study of all patients admitted for a finger replantation between July 2015 to January 2016. All patients were offered to partake in the PAP, or else they would constitute the control group. Primary endpoints were functional outcomes as reported by patients at 6-8weeks and 4-6months of follow-up. Secondary endpoints were patient-reported pain and quality of life questionnaires. In total, 62 patients were admitted for finger replantation in the studied period, in which 50 agreed to participate in the study, including 7 in the patient-advisors group and 43 in the control group. Patients from the patient-advisors group fared better on mean scores of the Disabilities of the Arm, Shoulder and Hand than controls (29.6 vs 34.8 respectively at 4-6months). Improvements in the McGill Pain Questionnaire were also greater in the studied group (19.9 vs 33.3 at 4-6months). Replantation patients benefiting from the PAP demonstrated superior functional outcomes on self-reported questionnaires, which could be explained by a better understanding of rehabilitation protocols and compliance when previous patients are active members of the treating team.

The Left Right Judgement Task (LRJT) involves determining if an image of the body part is of the left or right side. The LRJT has been utilized as part of rehabilitation treatment programs for persons with pain associated with musculoskeletal injuries and conditions. Although studies often attribute changes and improvement in LRJT performance to an altered body schema, imaging studies suggest that the LRJT implicates other cortical regions. We hypothesized that cognitive factors would be related to LRJT performance of hands and feet and that sensory, motor, and pain related factors would be related to LRJT in the affected hand of participants with wrist/hand pain. In an observational cross-sectional study, sixty-one participants with wrist/hand pain participated in a study assessing motor imagery ability, cognitive (Stroop test), sensory (Two-Point Orientation Discrimination, pressure pain thresholds), motor (grip strength, Purdue Pegboard Test), and pain related measures (West Haven Yale Multidimensional Pain Inventory) as well as disability (Disability of the Arm, Shoulder and Hand). Multiple linear regression found Stroop test time and motor imagery ability to be related to LRJT performance. Tactile acuity, motor performance, participation in general activities, and the taking of pain medications were predictors of LRJT accuracy in the affected hand. Participants who took pain medications performed poorly in both LRJT accuracy (p=0.001) and reaction time of the affected hand (p=0.009). These participants had poorer cognitive (p=0.013) and motor function (p=0.002), and higher pain severity scores (p=0.010). The results suggest that the LRJT is a complex mental task that involves cognitive, sensory, motor, and behavioural processes. Differences between persons with and without pain and improvement in LRJT performance may be attributed to any of these factors and should be considered in rehabilitation research and practice utilizing this task.

Peripheral nerve research as well as nerve repair simulation has relied heavily on the rat animal model, more specifically on the rat sciatic nerve.1 As the use of animals in experiments and training has received much criticism from animal rights activists and society at large, the field of surgical simulation is currently emerging. In microsurgery, high-fidelity Silastic models, animal parts such as chicken thighs or wings, and cadaveric specimens have been used. Based on the available experience with Thiel embalmed cadaveric tissue in simulation,2–4 we experimented with Thiel embalmed peripheral nerves for the purpose of microsurgical skill training. We used median, ulnar, and tibial nerves from cadavers that had been used for anatomic and surgical training and had not touched the peripheral nerve tissue. The donors had previously consented to tissue utilization in postmortem research. The tissues originated from cadavers prepared with the embalming method described by Thiel.5 This technique preserves texture, volume, color, and shape of the body as perfect as possible, with the advantage of avoiding decay observed with fresh cadaveric specimens. There is no shrinking or soaking of the soft tissues. Thirteen nerve sections measuring 5 cm eachwere prepared on a foam board. Needles (25 G) are used to fix the nerves to the foam board. A blue background was used for the exercise, as it improves contrast. An operating microscope (Opmi Pico, Carl Zeiss, Oberkochen, German) at 10 magnification was used for all microneurorrhaphies. Under magnification, the nerves were crushed in the midsection to simulate an injured nerve. The participants transected the nerve using a 15-blade scalpel, and trimmed the damagednerve tissue. The two endswere inspected for the fascicular architecture and oriented appropriately for the repair. The epineurium was then gently reflected back and the proud fascicles trimmed. Nylon 8–0 sutures were used to perform a simple epineural repair, starting with the 0and 180-degree orientation sutures and then filling in the required sutures to obtain a well-oriented microneurorrhaphy. Under magnification of the operative microscope, we found the Thiel nerve tissue to show a slight gray-brown discoloration with an epineural layer that was hydrophilic, giving the impression of edematous tissue (►Fig. 1). This thicker-than-normal epineural layer, however, offers adequate support for manipulation. Unfortunately, the cadaveric nature of themodel precludes the use of the vasa nervorum,which are not visible, for adequate orientation of the nerve. Upon transection of the nerve, it can be observed that the fascicles arewell preserved and bound byfirm endoneurium and perineurium which have not undergone the same edema as the epineurium (►Fig. 1). Despite therebeing no immediate herniation of nerve fascicles upon transection, the fascicles have a tendency to bemorehygroscopic, and by the end of the neurorrhaphy, one can observe some protrusion of fascicles in between suture. The fascicular pattern is easily identifiable and permits good alignment of the nerve before suturing. Thirteen volunteer plastic surgery, otolaryngology, and orthopedics residents utilized themodel once each, andfilled out a postsimulation survey. The results were graded on a five-point Likert scale (strongly agree, disagree, neither agree nor disagree, agree, strongly agree). A question regarding the frequency participants would use the laboratory with answers graded in five categories was also asked. The contents of the postsimulation survey are presented in ►Table 1. Descriptive statistics are presented for the results of the survey questions. All participants (100.0%) agreed that they would use themodule at least twice a year,with 53.9% (seven residents) stating theywoulduse itmore than once amonth, 38.5% (five residents) once amonth, and7.7% (one resident) twice a year. The rapid development of microsurgery over the last three decades has been echoed by the development of several simulation models for the teaching and honing of microsurgical skills. Free flaps are routine procedures in most plastic surgery centers, and residents have ample opportunity to participate and perform in these procedures. As a

Summary Background Staged expander-to-implant breast reconstruction is plagued by a high prevalence of complications. We have employed an alternative approach of using the infra-mammary crease (IMF) for expander-to-implant exchange. The IMF approach was thought to utilize healthier tissues, which are believed to be less affected by the process of tissue expansion, and reside distant from the field of the radiotherapy boost. Methods A retrospective chart review was performed on all patients undergoing a staged implant-based breast reconstruction from 2009 to 2014. Patients were divided into those that received an IMF vs. a mastectomy scar (MS) approach in the second stage of expander-to-implant exchange. Patient characteristics and postoperative complications were extracted. Results A total of 75 patients undergoing 96-staged reconstructions were included (70 cases MS vs. 26 cases IMF). Patient demographics and implant characteristics were similar between groups. There were no significant differences in overall complications between the groups (11.4% MS vs. 7.7% IMF, P = 0.72). All cases of implant exposure occurred in the MS group and had a history of radiation. However, there was no statistical difference in implant exposure between groups (4.3% MS vs. 0% IMF, P = 0.56) or in the irradiated patients subgroup (20% MS vs. 0% IMF, P = 0.25). Conclusions In conclusion, the IMF approach for the second stage of expander-to-implant exchange is an alternative technique with a similar prevalence of complications as the traditional mastectomy scar approach. This technique may prove useful in reducing postoperative incisional dehiscence and implant exposure, especially in the context of radiotherapy.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Summary Background Venous congestion/insufficiency plays a major role in failure of finger replantation. Despite acceptable salvage rates with postoperative anticoagulation or leeching, operative technique remains the most important predictor of success. However, there are no indications in the literature on the benefit of anastomosing single versus multiple veins. Methods A retrospective review of finger amputations from 2011 to 2013 was conducted. The analyzed endpoint was the finger survival rate at discharge depending on the number of veins repaired: multiple veins (group 1), only one vein (group 2), or no veins (group 3). Proportions were compared using v2 tests/Fisher's exact tests; p- value Results Seventy-two patients with complete digital amputation were operated including 101 fingers. Twenty-seven fingers (26.7%) failed before hospital discharge, with 78% of failures due to venous complications versus 22% with an arterial etiology. Group 2 had 15 replantation failures due to venous causes as opposed to only one from group 1, representing a 1.27-fold (95% confidence interval (CI): 0.99, 1.34) increased relative risk of failure ( p = 0.032). Similarly, five fingers from group 3 suffered venous complications, resulting in a 1.49-fold (95% CI: 1.02, 1.73) increased likelihood of failure in comparison to group 1 ( p = 0.008). No significant difference was observed between having only one vein repaired versus none (RR: 1.1792, 95% CI: 0.83, 2.10, p = 0.502). Conclusion Efforts toward favoring two-vein repair lead to better survival of the replanted fingers. More cases need to be analyzed before formulating conclusions on specific levels of amputation with regard to venous anastomoses.

Even though self-confidence is a popular concept both in everyday life and in psychology, no individual difference measure is available. The purpose of this study was to construct and validate an 18-item self-confidence scale. A sample of 191 white undergraduate students from Université du Québec à Trois-Rivières (44 men and 147 women) participated. An exploratory factor analysis indicated two distinct factors; one measured a general cognitive aspect of self-confidence and a second evaluated a more specific self-confidence in one's abilities and opinions. Internal consistency (Cronbach α) was .84. Intercorrelations with other related measures (.23 to .69) were significant and in the expected direction. The new scale could be useful when a specific measure of self-confidence is required as an individual difference measure.

The present study looked at others' reactions to dissonant behaviors in a domain particularly sensitive to such discrepancies, i.e., religious observances. We might often say we are Catholic/Protestant, etc. and educate our children as such but personally not practice religion. How do children react to such inconsistencies? In a study of 210 high school students we determined congruent/incongruent parents and extent of their children's worry or upset based on their answers to a questionnaire designed for this purpose. Apparently children are well aware of such inconsistencies and multivariate analyses of variance show that children of incongruent parents are significantly more troubled, more upset with their parents' behavioral incongruities than are children of congruent parents. Also of interest is that boys and girls reacted in the same manner and no interactions were found. It appears to be important for parents to be aware of the negative consequences their inconsistent behaviors have on their children.

It is now well recognized that poorly accepted children run a greater risk of serious adjustment problems later in life. The poor-to-fair temporal reliability of the peer-nominations found among young children was an obstacle to early assessment. Although two reliable alternative techniques have been proposed, these have important drawbacks. The present study assessed the reliability of a third alternative, namely, asking children to make more nominations. Three to six positive and negative nominations were obtained from 97 kindergarten and 100 prekindergarten children. Although data proved unreliable at the prekindergarten level, data from kindergarten children were quite reliable and indicated that four choices yielded higher reliabilities than three-choice nominations. More nominations did not further improve reliability. Percentages of subjects classified in the various sociometric status following Coie and Dodge's 1983 criteria also suggested that four choices reproduced optimally the classification generated by the traditional nomination technique. Implications of these results are discussed.