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Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background  Phrenic nerve reconstruction has been evaluated as a method of restoring functional activity and may be an effective alternative to diaphragm plication. Longer follow-up and a larger cohort for analysis are necessary to confirm the efficacy of this procedure for diaphragmatic paralysis. Methods  A total of 180 patients treated with phrenic nerve reconstruction for chronic diaphragmatic paralysis were followed for a median 2.7 years. Assessment parameters included: 36-Item Short Form Health Survey (SF-36) physical functioning survey, spirometry, chest fluoroscopy, electrodiagnostic evaluation, a five-item questionnaire to assess specific functional issues, and overall patient-reported outcome. Results  Overall, 134 males and 46 females with an average age of 56 years (range: 10-79 years) were treated. Mean baseline percent predicted values for forced expiratory volume in 1 second, forced vital capacity, vital capacity, and total lung capacity, were 61, 63, 67, and 75%, respectively. The corresponding percent improvements in percent predicted values were: 11, 6, 9, and 13% ( p ≤ 0.01; ≤ 0.01; ≤ 0.05; ≤ 0.01). Mean preoperative SF-36 physical functioning survey scores were 39%, and an improvement to 65% was demonstrated following surgery ( p  ≤ 0.0001). Nerve conduction latency, improved by an average 23% ( p  ≤ 0.005), and there was a corresponding 125% increase in diaphragm motor amplitude ( p  ≤ 0.0001). A total of 89% of patients reported an overall improvement in breathing function. Conclusion  Long-term assessment of phrenic nerve reconstruction for diaphragmatic paralysis indicates functional correction and symptomatic relief., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options., Methods: An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications., Results: In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values., Conclusions: Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Unilateral phrenic nerve injury often results in symptomatic hemidiaphragm paralysis, and currently few treatment options exist. Reported etiologies include cardiac surgery, neck surgery, chiropractic manipulation, and interscalene nerve blocks. Although diaphragmatic plication has been an option for treatment, the ideal treatment would be restoration of function to the paralyzed hemidiaphragm. The application of peripheral nerve surgery techniques for phrenic nerve injuries has not been adequately evaluated., Methods: Twelve patients presenting with long-term, symptomatic, unilateral phrenic nerve injuries following surgery, chiropractic manipulation, trauma, or anesthetic blocks underwent a comprehensive evaluation, including radiographic and electrophysiologic assessments. Surgical treatment was offered following a minimum of 6 months of conservative management. Operative planning was based on preoperative and intraoperative testing using one or more established nerve reconstruction techniques (neurolysis, interpositional grafting, or neurotization)., Results: Measures of postoperative improvement included pulmonary function testing, fluoroscopic sniff testing, and a standardized quality-of-life survey, from which it was determined that eight of nine patients who could be completely evaluated experienced improvements in diaphragmatic function., Conclusions: Based on the favorable results in this small series, we suggest expanding nerve reconstruction techniques to phrenic nerve injury treatment and propose an algorithm for treatment of unilateral phrenic nerve injury that may expand the current limitations in therapy.

Background: A single surgeon's experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively., Methods: Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n = 11), dorsal wrist and hand (n = 24), palmar wrist and hand (n = 12), and thumb amputations (n = 5); after release of thumb-index finger web space contractures (n = 6) and radioulnar synostosis (n = 2); before toe-to-thumb transfers (n = 3); for reconstruction following tumor excision (n = 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis (n = 5)., Results: Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution., Conclusions: This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedicled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand.

Background: Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care., Methods: A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions., Results: Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient's life, occurred in 5 percent of the patients, but there was a 37 percent incidence of "minor" medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs., Conclusion: Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

Background: Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners., Methods: Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results., Results: The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent)., Conclusion: Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.