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Dermatosis neglecta or dermatitis neglecta is a condition which occurs due to inadequate cleansing of a localised area of skin resulting in the accumulation of dirt, sebum, sweat, corneocytes and bacteria. These patients do not clean the area due to various reasons like pain at the site, prior surgery, physical disability, neurological deficit, or psychiatric illness. Vigorous rubbing of the lesion with alcohol soaked gauze results in removal of the lesion. We report a case of dermatosis neglecta in a 50 year old lady with carcinoma breast following mastectomy on the right side. She did not clean the area adequately as she was scared that the area of suture after mastectomy would give way, thus resulting in hyperkeratotic lesions.

Microvascular free tissue transfer has revolutionized reconstruction and subsequently functional outcomes in the head and neck, but requires suitable recipient vessels for successful results. Recipient vessels can be significantly compromised by prior surgery, radiation therapy, or existing and/or underlying vascular disease in the neck. When further microvascular reconstruction is required in the vessel-depleted neck, identification of appropriate vessels for anastomosis can be difficult and can present complex decisions for the surgeon as well as the patient. In this article, we review the available literature on the vessel depleted neck and the possible vessel options. We present critical strategies for preoperative treatment planning and vessel selection in these patients. We also discuss the benefits and limitations of arterial and venous options while commenting on our unique institution's experiences. The external carotid branches as well as the available subclavian artery branches are presented in detail. The venous anatomy is also described, with particular focus on the accompanying veins and cephalic vein. We provide guidance on the selection and modification of free flaps to achieve the greatest function and cosmetic outcomes in the vessel depleted neck. Our collection of advanced management techniques will provide surgeons with more options to manage the complexity of the vessel depleted neck, and to further help patients understand the risk and benefits of these selections.

Item does not contain fulltext Dorsal root ganglion stimulation (DRG-S) has shown promise as a treatment for low back pain. The traditional anterograde placement of DRG-S leads can be challenging in patients with anatomical changes from prior back surgery. We describe an "outside-in" placement technique of DRG-S leads in 4 patients with histories of multiple lumbar surgeries, which made the traditional anterograde placement not feasible. At long-term follow-up, the patients experienced substantial pain relief and improvement in quality of life, with no complications. The outside-in lead placement technique may be an efficacious alternative to the traditional techniques in patients with anomalous anatomy from prior surgery.

Background This study compares outcomes of reverse total shoulder arthroplasty (RTSA) in patients with prior rotator cuff repair to matched control patients without prior surgery. Patients and methods All primary RTSAs with prior surgery were retrospectively identified from a prospective research database between 2000 and 2014. RTSA patients with prior open or arthroscopic rotator cuff repair and minimum 2-year follow-up, with age- and sex-matched controls, were identified. Active range of motion (ROM) and functional outcomes were evaluated. Preoperative, postoperative and improvement in outcomes were compared between groups. Results One hundred fifty RTSA patients were included, with 75 patients in each group (42 female, 33 male). Mean age of the RTSA group with prior rotator cuff repair was 69.6 years (average follow-up, 3.8 years) compared to the RTSA group without prior surgery (control) aged 70.0 years (average follow-up, 3.3 years). Preoperatively and postoperatively, RTSA patients with prior cuff repair had slightly worse overhead ROM and outcome scores compared to controls but none were statistically different. The RTSA and control groups had similar and significant improvements in all postoperative ROM and outcome scores. Complications were similar between groups. Discussion RTSA patients with prior rotator cuff repair had similar ROM, functional outcome scores, and complications compared to a matched control group without prior surgery. Level of Evidence III, Treatment Study.

Background The absence of a tumor specimen from which to obtain measurements at the time of delayed maxillomandibular reconstruction introduces degrees of uncertainty, creating the need for substantial intraoperative guesswork by the surgeon. Using the virtual surgical planning environment, the size and shape of missing bony elements is determined, effectively "recreating the defect" in advance of the surgery. Three virtual surgical planning techniques assist the reconstructive surgeon: patient-specific modeling, mirroring the normal contralateral side, and scaled normative data. To facilitate delayed reconstruction a hierarchical algorithm using virtual surgical planning techniques was developed. Methods Delayed maxillomandibular virtual surgical planning reconstructions were identified from 2009 to 2016. Demographics, modeling techniques, and surgical characteristics were analyzed. Results Sixteen reconstructions were performed for osteoradionecrosis with displacement (50.0 percent) or oncologic defects (37.5 percent). Most patients had prior surgery (81.3 percent) and preoperative radiation therapy (81.3 percent); four had failed prior reconstructions. The following delayed virtual surgical planning techniques were used: patient-specific modeling based on previous imaging (43.8 percent), mirroring normal contralateral anatomy (37.5 percent), and scaled normative data (18.8 percent). Normative and mirrored reconstructions were designed to restore normal anatomy; however, most patient-specific virtual surgical planning designs (71.4 percent) required nonanatomical reconstructions to accommodate soft-tissue limitations and to avoid the need for a second flap. One partial flap loss required a second free flap, and one total flap failure occurred. Hardware exposure was the most common minor complication, followed by infection, dehiscence, and sinus tract formation. Conclusions Virtual surgical planning has inherent advantages in delayed reconstruction when compared to traditional flap shaping techniques. An algorithmic approach based on available imaging and remaining native anatomy enables accurate reconstructive planning followed by flap transfer without the need for intraoperative guesswork. Clinical question/level of evidence Therapeutic, IV.

The lateral canthus is a complex region that requires a deep understanding of its structure and physiology for safe and effective oculofacial surgery. Aging, prior surgery, infection, neoplasm, and trauma are just some of the ways the lateral canthus can be altered. In this highly visible area, surgeries involving the lateral canthus impact function and appearance. Below, we detail the anatomy of the lateral canthus, preoperative considerations, and lateral canthal surgical techniques.

BACKGROUND Limited data exist on the safety of overlapping surgery, a practice that has recently received widespread attention. OBJECTIVE To examine the association of overlapping neurosurgery with patient outcomes. METHODS A total of 3038 routinely scheduled, elective neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. Procedures were categorized into any overlap or no overlap and further subcategorized into beginning overlap (first 50% of procedure only), end overlap (last 50% of procedure only), and middle overlap (overlap at the midpoint). RESULTS A total of 1030 (33.9%) procedures had any overlap, whereas 278 (9.2%) had beginning overlap, 190 (6.3%) had end overlap, and 476 (15.7%) had middle overlap. Compared with no overlap patients, patients with any overlap had lower American Society of Anesthesiologists scores (P = .0018), less prior surgery (P

Background Few studies have focused on shoulder arthroplasty after anterior stabilization procedures. This study compares the outcomes of total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) after anterior stabilization surgical procedures. Methods All primary shoulder arthroplasties from 2000 to 2014 with prior surgery were retrospectively reviewed from a prospective research database. The inclusion criteria were primary TSA or RTSA, a history of anterior stabilization surgery, and minimum 2-year follow-up. Soft-tissue and bony anterior stabilization procedures were included. We compared the following between TSA and RTSA patients: active range of motion (ROM) and Shoulder Pain and Disability Index 130; Simple Shoulder Test; American Shoulder and Elbow Surgeons (ASES); Short Form 12; University of California, Los Angeles; and Constant scores. The RTSA group was also compared with an RTSA control group. Results The study included 15 TSA and 10 RTSA patients with average follow-up periods of 3.3 and 4.0 years, respectively. RTSA patients experienced greater improvements in all ROMs except internal rotation; these were not statistically significant despite the mean values for RTSA being above the minimal clinically important difference compared with TSA for forward flexion and abduction. RTSA patients had better improvements in all functional outcomes; only the ASES score was statistically significant. TSA patients had a 33% complication rate and a 20% reoperation rate. RTSA patients had no complications or reoperations. The group that underwent RTSA with prior anterior stabilization surgery had similar improvements in ROM and outcome measures to the RTSA control group. Conclusion RTSA patients had better postoperative improvement in most ROMs and all functional scores; only the ASES score was statistically significant. This study suggests better outcomes with a lower complication rate with RTSA after prior anterior stabilization procedures compared with TSA.

Literatures have showed that deep learning models can detect a breast cancer with high diagnostic accuracy in the publicly available mammography datasets. The objective of this study is to examine whether the high performance (accuracy) of a deep learning model, trained by the public mammography dataset, can be transferred into the clinic practice by applying it to a new mammography dataset obtained in an academic breast center. An end-to-end CNN architecture was trained on DDSM dataset and transferred to INbreast dataset and the in-house collected dataset. The model achieved validation AUC of 0.82 on DDSM dataset and 0.93 on INbreast dataset. However, it only achieved 0.70 when applied to the in-house dataset. Reviewing the images revealed that the in-house dataset is more challenging to classify. The mean subtlety score for DDSM dataset is 3.64 and median is 4. For in-house dataset, the mean and median scores are 2.65 and 2, respectively. In addition, the in-house dataset has more co-existing benign abnormalities as more patients with benign biopsy or prior surgery return for mammography. These observations are in line with other institutes’ finding that the relative percentage of early stage cancer cases from mammography diagnosis has more than tripled since 2002. This indicates that currently available public open datasets may be inadequate to represent the mammography seen in today’s clinical practice. It is necessary to build an updated mammography database that contains sufficient pathological heterogeneity of breast cancer and coexisting benign abnormalities that reflect the cases seen in current practice.

Outcomes of shoulder surgery in workers' compensation (WC) patients have generally been inferior to those in non-WC patients. The purpose of this study was to compare the complication rates and clinical outcomes after shoulder arthroplasty in WC patients and control non-WC patients.An institutional shoulder arthroplasty database was queried for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. WC patients were age and sex matched with non-WC patients and retrospectively evaluated for complication rates, patient-reported outcome (PRO) scores, and range of motion.We matched 45 WC and 45 non-WC patients by age and sex, with the WC group having a higher rate of prior surgery (82% vs 38%, P .001). Both groups experienced significant improvements in all PROs, forward elevation, and external rotation (P .05 for all). The WC group had inferior 2-year outcomes for all PROs and forward elevation (P ≤ .001 for all), as well as a higher reoperation rate (16% vs 2%, P = .030) and higher rate of persistent pain at final follow-up (33% vs 11%, P = .021). On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in American Shoulder and Elbow Surgeons (P .001), functional (P .001), and Simple Shoulder Test (P .001) scores, as well as a higher reoperation rate (P = .015) and higher rate of persistent pain (P = .027).Although both WC and non-WC patients experienced significant clinical improvements after shoulder arthroplasty, WC patients had a higher reoperation rate, inferior PROs, and a higher rate of persistent pain.

Adults with congenital heart defects (ACHD) face long-term complications related to prior surgery, abnormal anatomy, and acquired cardiovascular conditions. Although self-care is an important part of chronic illness management, few studies have explored self-care in the ACHD population. The purpose of this study is to describe self-care and its antecedents in the ACHD population.Persons with moderate or severe ACHD (N=132) were recruited from a single ACHD center. Self-care (health maintenance behaviors, monitoring and management of symptoms), and potential antecedents including sociodemographic and clinical characteristics, ACHD knowledge, behavioral characteristics (depressive symptoms and self-efficacy), and family-related factors (parental overprotection and perceived family support) were collected via self-report and chart review. Multiple regression was used to identify antecedents of self-care maintenance, monitoring, and management.Only 44.7%, 27.3%, and 23.3% of participants performed adequate levels of self-care maintenance, monitoring and management, respectively. In multiple regression analysis, self-efficacy, education, gender, perceived family support, and comorbidities explained 25% of the variance in self-care maintenance (R(2)=.248, F(5, 123)=9.44, p.001). Age, depressive symptoms, self-efficacy, and NYHA Class explained 23% of the variance in self-care monitoring (R(2)=.232, F(2, 124)=10.66, p.001). Self-efficacy and NYHA Class explained 9% of the variance in self-care management (R(2)=.094, F(2, 80)=5.27, p=.007).Low levels of self-care are common among persons with ACHD. Multiple factors, including modifiable factors of self-efficacy, depressive symptoms, and perceived family support, are associated with self-care and should be considered in designing future interventions to improve outcomes in the ACHD population.

Crohn׳s disease (CD) is a chronic inflammatory disease of the intestinal tract characterized by transmural inflammation, which can progress to intestinal perforation, intra-abdominal abscesses, intestinal strictures, and fistula development. Surgery is frequently required to correct these disease-related complications. Unfortunately, there is no medical or surgical cure for the disease, and the etiology remains undefined. Thus, many patients will undergo multiple operations over their lifetime when the disease process becomes medically refractory and complications ensue. The index operation in CD can be challenging due to the active disease and any associated inflammation in non-diseased bowel. However, reoperative CD surgery even more complex due to the underlying disease process, adhesive disease, altered anatomy from the prior surgery or surgeries and the imperative to preserve small bowel. Several steps can be taken in the preoperative phase to optimize outcomes, and there are many technical aspects should be considered during the reoperation to assist in the performance of a safe operation and attempt to minimize intestinal resection. Herein, we review some of the important principles of operative and reoperative Crohn׳s surgery that can assist the operating surgeon when approaching this challenging patient population.

Background: The purpose of this study was to prospectively evaluate and compare the long-term clinical and radiographic outcomes of using osteochondral autograft and allograft to manage either recurrent or large osteochondral lesions of the talar dome (OLT) in a single surgeon’s practice. Methods: Between January 2008 and January 2014, a total of 40 patients presented with either a recurrent OLT that failed initial arthroscopic treatment (ie, excision, curettage, debridement, and micro-fracture) or a primary OLT greater than 1.5 cm2 that had undergone no prior surgery. Before surgery, 20 patients were randomized to receive osteochondral autograft plugs (Arthrex, Naples, FL) from the ipsilateral superolateral distal femoral condyle whereas the remaining 20 were randomized to receive osteochondral allograft plugs from a fresh size-matched donor talus (Joint Restoration Foundation, Centennial, CO, and Arthrex, Naples, FL), but 4 of these were excluded that received a hemi-talus allograft with internal fixation. Preoperative and postoperative function and pain was graded using the Foot and Ankle Ability Measures (FAAM) scoring system and a Visual Analog Scale (VAS) of pain, respectively. Radiographs were assessed for osteochondral graft healing, joint congruency, and degenerative changes. Data regarding postoperative complications and revision surgeries were also recorded. Results: Of the 20 patients who received osteochondral autograft, the mean FAAM score increased from 54.4 preoperatively to 85.5 at the time of final follow-up. The mean VAS pain score decreased from 7.9 of 10 preoperatively to 2.2 of 10 at final follow-up. Two patients (10%) that received osteochondral autograft, 1 for a recurrent OLT of 1.3 cm2 and 1 for a primary OLT of 2.0 cm2, developed a symptomatic nonunion at the entire graft site. Both of these patients had their autograft converted to talar allograft plugs and achieved full osteochondral healing. At the time of final follow-up, no patients who received osteochondral autograft developed ankle degenerative changes or knee complications. The mean FAAM score of the 16 patients who received osteochondral allograft plugs increased from 55.2 preoperatively to 80.7 at the time of final follow-up. This postoperative score was lower than that of the osteochondral autograft group, but not to a statistically significant degree ( P = .25). The mean VAS pain score decreased from 7.8 of 10 preoperatively to 2.7 of 10 at final follow-up. This postoperative score was higher than that of the osteochondral autograft group but not to a statistically significant degree ( P = .15). Three patients (18.8%) that received osteochondral talar allograft, 2 for recurrent OLTs less than 1.5 cm2 and 1 for a primary OLT of 2.2 cm2, developed a symptomatic nonunion at the entire graft site. Two of these 3 patients had their allograft converted to osteochondral autograft plugs harvested from the ipsilateral superolateral distal femoral condyle and achieved full osteochondral healing. At the time of final follow-up, 1 of these 16 (6.3%) patients who received talar allograft as OLT treatment had developed asymptomatic anterior ankle arthritis upon radiographs. Conclusion: Using fresh talar osteochondral allograft provided results that were comparable to the use of distal femoral osteochondral autograft for treating recurrent or large OLTs. Although the use of allograft avoided the risk of knee complications when harvesting autograft from the distal femur, fresh talar allograft may have lower healing rates than osteochondral autograft. Level of Evidence: Level II, comparative case series.

Background Patients with PMCA commonly undergo surgery before CRS/HIPEC. We evaluated the role of extensive surgical treatment before CRS/HIPEC in terms of overall survival (OS). Methods 105 patients with PMCA who underwent a CRS/HIPEC procedure were identified from a prospective database. Patients were divided into two groups based on Prior Surgery Score (PSS): PSS ≤1 limited surgery group (LSG), PSS >1 extensive surgery group (ESG). Survival of lymph node (LN) negative and positive patients was analyzed separately. Results 40 patients were in LSG and 65 in ESG. Mean time from diagnosis to CRS/HIPEC was 6 and 17 months for LSG and ESG, respectively (p = 0.004). Groups were well balanced in peritoneal cancer index, complete cytoreduction rate, and LN status. One, 3, and 5-year OS among LN negative patients was 95, 83, and 75% for the LSG (n = 22) group and 87, 55, and 32% for the ESG (n = 35), group respectively (p = 0.026). One, 3, and 5-year OS among LN positive patients was 69, 50, and 17% for the LSG (n = 18) group and 80, 21, and 14% for the ESG (n = 30), group respectively (p = 0.613). For all patients 1, 3, and 5-year OS was 84, 65, and 54% for the LSG (n = 40) group and 86, 43, and 26% for the ESG (n = 65) group, respectively (p = 0.029). Conclusion Extensive surgical treatment before CRS/HIPEC is associated with delay of CRS/HIPEC and poorer OS overall, especially among LN negative patients. We recommend early referral of PMCA patients to a peritoneal surface malignancy center.

Background Esotropia due to high myopia can be caused by inferior shift of the lateral rectus muscle (LRM). Innovative surgical methods have been developed to elevate the muscle and, thus, augment its abducting force. However, their efficacy is not yet proven to exceed that of recess–resect surgery (RR). Methods Data on high myopic esotropia were evaluated who received RR together with elevation of the LRM in the horizontal meridian by equatorial myopexy. Age, gender, axial length, amount of surgery, preoperative and 3 months postoperative strabismus angles and efficacy (mm/°) were analysed. Medians and ranges (minimum–maximum) are given. Results The age of the 46 patients (37 females, 9 males) was 57 years (36–76). Axial length was 31.5 mm (26.0–35.6), total amount of RR 10.0 mm (5–24). Esotropia 16° (4–60) was reduced to 2° (−22 to 34), hypotropia from 3° (−3 to 30) to 0° (−8 to 18). Efficacy (eyes without prior surgery only) was 1.33°/mm (0.20–3.55). Conclusions Geometrical considerations rather than empirical data yield some evidence of an augmenting effect of equatorial myopexy on RR. Efficacy of RR with LRM myopexy was higher in unilateral than bilateral high myopia. Strict indication for myopexy appears appropriate.

Purpose: To evaluate outcomes of proton therapy and x-ray radiation treatments for head and neck paragangliomas. Patients and Methods: Between 2004 and 2014, 13 patients with paragangliomas were treated with radiation using proton therapy (n = 7) or x-ray modalities (n = 6). Paragangliomas were jugular fossa, vagal, tympanic, and carotid body in 5, 4, 2, and 2 patients, respectively. Patients were treated definitively (n = 8), for recurrence or progression after prior surgery (n = 4), or for residual tumor after surgery (n = 1). The median age was 55 years (range, 35 to 77 years). The median dose of proton therapy was 35 Gy (RBE) in 15 fractions, and 50.4 Gy in 28 fractions for those treated with x-rays. Tumor volume was delineated at treatment planning and on follow-up images to assess volumetric changes over time. The median follow-up time after proton therapy was 52 months (range, 6 to 105 months) and 73 months (range, 37 to 91 months) after x-ray therapy. Results: No acute grade 3 or greater ...

A young old male presented with a 2 months history of recurrent disc prolapse 10 years after prior surgery. He was operated for L4-L5 disc prolapse 10 years ago. Fresh MRI showed prolapsed intervertebral disk (PIVD) at L5-S1 level with a spherical mass lesion of 2.5x2x2 cm with well defined margin in the left paraspinal area adjacent to L5 lamina. The patient had symptoms of L5-S1 PIVD but absolutely no local or systemic symptom for the mass. On exploration, a retained gauge piece was found in the left paraspinal area.

Highlights • Internal hernias are difficult to diagnose given their vague, non-specific presentation; they should always be on the clinician’s differential for SBO symptoms. • Acquired internal hernias develop most often due to adhesions or mesenteric defects from prior surgery. • Congenital internal hernias can arise from peritoneal defects. • We present the first reported case of an SBO from a congenital vesico-uterine defect., Introduction An internal hernia is a rare type of hernia that may either be congenital or acquired in etiology. Acquired internal hernias generally develop from mesenteric defects or adhesions from prior surgery. These hernias can trap and/or twist small bowel, resulting in bowel obstruction. The diagnosis of small bowel obstruction (SBO) secondary to internal hernia is particularly challenging given its non-specific clinical presentation. Thus, it is critical for the clinician to keep internal hernias as part of the differential for a patient presenting with SBO. Presentation of case In this case, we present the first reported case of a hernia through the vesico-uterine space as a cause of an SBO. Our patient was a 38-year-old female with no past medical or surgical history who presents with nausea, vomiting, and obstipation. Upon exploratory laparoscopy, she was found to have an internal hernia through a peritoneal defect in the vesico-uterine space. Discussion To our knowledge this is the first report of an intestinal obstruction caused by herniated bowel through a congenital vesico-uterine peritoneal defect. It is important for surgeons to keep in mind that while rare, congenital pelvic peritoneal defects can lead to bowel obstructions. Conclusion The patient underwent laparoscopic exploration, during which the incarcerated bowel was freed and appeared to be viable. The peritoneal defect was subsequently closed. Post-operatively, she recovered without issues and her obstructive symptoms resolved.

Background Aim of this investigation was to analyze whether patients undergoing humeral head resurfacing (HHR) surgery are able to successfully return to their sports and occupation afterwards. Materials and methods Fifty patients treated with CUP (HHR) arthroplasty were included. Two groups were built: Patients who have participated in sports less than 5 years prior surgery (Group 1: n = 42 (84%)) and patients who have never participated in sports (Group 2: n = 8 (16%)). Evaluation was based on a questionnaire asking for types of sports, frequency, time to return to sports and work as well as limitations in work life. Results Mean age at the time of surgery was 58.6 (36–84) years in Group 1 and 65 (56–75) years in Group 2. Mean time follow-up was 5.5 years (2.5–12) years. Twenty-seven (64%) patients in Group 1 participated in sports right before surgery. Twenty-one patients (50%) returned to sports after surgery. The returning rate was 78%. Seven (17%) patients in Group 1 stated that the reason they underwent shoulder replacement surgery was to continue to participate in sports. Swimming and skiing were two of the most favorable sports. Two (4%) patients had to change their profession due to surgery. Most of the patients were retired at follow-up. Conclusion Most of the active patients undergoing HHR surgery are successfully able to return to their sports activities after surgery. Patients employed were able to return to their occupation after surgery. Many patients were already retired at the time of follow up.

Rupture of the patella tendon during or following total knee arthroplasty (TKA) can be an extremely challenging complication to manage. The following case reports will describe several surgical options for the management of patella tendon ruptures, but it is important to identify those patients who are at greater risk for rupture of the patella tendon. Those patients at higher risk tend to be obese, have limited preoperative range of motion, have had prior surgery, or have a metabolic condition or connective tissue disorder that may compromise the patella tendon.

IPOR, Alper Murat/0000-0002-9855-9050 WOS: 000427230200001 PubMed: 29682274 Thyroid reoperations are surgically challenging because of scarring and disturbances in the anatomy of the recurrent laryngeal nerve (RLN). This study was conducted on 49 patients who underwent redo surgery. 61 RLNs were identified and completely exposed. Their functional integrity was evaluated using intraoperative nerve monitoring (IONM). Indications for secondary surgery, anatomical changes secondary to recurrent goiter mass and prior surgery, and results of IONM were studied. Frequent indications for redo surgery were multinodular goiter (MNG) in 19 (38.8%) and results of cytology in 14 (28.5%) patients. The mean time interval between primary and redo thyroid surgery was 23.4 years. We laterally approached 41 (67.2%) thyroid lobes between the sternocleidomastoid and sternohyoid muscles. 16 (26.2%) RLNs were found to be adherent to the lateral surface of the corresponding thyroid lobe. The functional integrity of all RLNs was confirmed by IONM. The remnant thyroid tissue can then lead to goiter recurrence requiring secondary surgery after a long period of time. The indications for redo surgery were similar to primary cases. Lateral displacement of the RLN which is adherent to the lateral surface of recurrent goiter mass is common anatomic variation. Thyroid reoperations based on awareness of anatomical disturbances can be performed safely by an experienced surgeon with support of ancillary electrophysiological technology.

Diastasis recti is a midline contour abnormality of the anterior abdominal wall that is characterized by the attenuation of the linea alba and usually is sequelae of pregnancy. Other causes include prior surgery and obesity. It is differentiated from a true hernia based on the absence of a fascial defect. Management options are diverse and well described and include a wide range from conditioning exercises to surgical repair with or without mesh. This chapter will review the characteristics and treatment modalities for diastasis recti.

Skin antisepsis prior to invasive procedures, hand hygiene performed by health care workers, sterilization and disinfection of medical devices and environmental surfaces are the most important measures used to control nosocomial infections. Hand hygiene is the cheapest and most effective measure. Hand rubbing with an alcohol-based hand rub is recommended for the routine decontamination of hands. Hand washing with soap and water should be employed when hands are visibly soiled, and when exposure to Clostridium difficile infection is suspected or proven. Most alcohol based hand rubs are based on isopropanol, ethanol or n-propanol. The WHO published guidance recommend 20-30 seconds for routine hand rubbing. There are no recommendations stating that antimicrobial soaps are more effective than plain soaps. It is recommended to use alcohol-containing preparatory agents for skin preparation prior surgery, injections, incisions and punctures. Neutral pH detergent solutions are commonly used for cleaning equipment and instruments. Data did not clearly demonstrate that enzymatic cleaners are more effective than non-enzymatic cleaners. High level disinfection is safe procedure only if adequate products are properly used. There are no any special products for multidrug resistant bacteria.

Over the years there have been numerous anecdotal reports of nasal tip enlargement and loss of tip definition post rhinoplasty. Subsequent revisionary procedures not only failed to reduce the tip size but aggravated the problem causing an even larger and less defined nasal tip. The final result was often worse than the preop condition and uncorrectable. Six patients who demonstrated an aggravation of the postop result with subsequent revisionary or secondary surgeries were evaluated to find common causes or circumstances. All patients had 1) worsening of nasal tip result with subsequent procedures, e. g., nasal tip enlargement and/or loss of tip definition with subsequent procedures 2) exhibited substantial postop edema at one or more surgeries and 3) extensive subcutaneous fibrous tissue noted at revisionary procedures. The nasal scenario described is referred to as postrhinoplasty fibrotic syndrome. It is recommended that if revision surgery is necessary by a surgeon, the scale of the surgery should be smaller than that of the primary operation. If yet another revision is necessary that surgery should be of an even smaller scale than the prior surgery. Augmentation rather than reduction rhinoplasty is clearly a better approach. With the surgical philosophy of smaller and/or less surgery with each revision (should it be necessary) the irreversible condition of postrhinoplasty fibrotic syndrome should be avoidable.

Mobilization of the hepatic flexure is a necessary component of the right hemicolectomy, as well as several other colorectal procedures. This step can be challenging in certain patient populations, such as the obese patients that had prior surgery in the right upper quadrant or patients with foreshortened mesentery or thick omentum. Given this, approaching the hepatic flexure in this stepwise fashion could help ensure a successful mobilization.

Background Surgery for stress urinary incontinence (SUI) has been dominated recently by synthetic midurethral tapes. Increasing recognition of serious complications associated with nonabsorbable polypropylene mesh has led to resurgence in interest in alternative approaches, such as the autologous fascial sling (AFS). Despite being an efficacious and durable option in women with recurrent and complex SUI, there has been a reluctance to consider AFS in women with primary SUI due to a perception that it is only appropriate for treating patients with intrinsic sphincter deficiency (ISD) and is associated with high rates of urinary retention and de novo storage symptoms. Objective The video presented demonstrates the technique for a loosely applied midurethral AFS. In contrast to AFS applied at the bladder neck, this technical modification in patients who demonstrate primary SUI without ISD avoids high rates of de novo storage symptoms and urinary retention. Design, setting, and participants A retrospective review of data on patients undergoing AFS at a tertiary referral unit. Surgical procedure AFS placement in a "loose" fashion using a short length of fascia suspended on a suture bilaterally at the midurethral level rather than at the bladder neck and only using more tension in patients with ISD. Measurements Subjective cure rate, rates of postoperative storage symptoms, and urinary retention necessitating intermittent self-catheterisation (ISC). Results and limitations A total of 106 patients underwent AFS; the mean follow-up period was 9 mo. The mean age was 52.6 (range 24–83) yr. In total, 46.2% had primary SUI, whilst all of the remaining 53.8% had undergone prior surgical intervention. Overall subjective cure occurred in 79.2% of patients; a further 15.1% described significant subjective improvement in symptoms, whilst 5.7% reported no change in symptoms. In those with primary SUI, rates of subjective cure, improvement, and nonresolution of symptoms were 87.8%, 12.2%, and 0%, respectively. In individuals with prior surgical intervention, rates of subjective cure, improvement, and nonresolution of symptoms were 72.0%, 17.5%, and 10.5%, respectively. De novo storage symptoms occurred in 8.2% of those with primary SUI compared with 14.0% of those with prior surgical intervention. Only 2.0% patients with primary SUI needed to perform ISC beyond 2 wk compared with 10.5% of those after prior surgery. Conclusions A midurethral AFS appears to be effective and safe both in women with primary SUI who want to avoid the placement of permanent material and its attendant risks, and in more complex cases where this is less appropriate. Patient summary A graft taken from the covering of the abdominal muscle or the outer aspect of the thigh is an alternative to a synthetic vaginal mesh in women who have stress urinary incontinence requiring surgical treatment. Placing the graft loosely at the midpoint of the urethral tube, rather than at the bladder neck, reduces the risk of postoperative voiding difficulty and overactive bladder symptoms. Long-term data have suggested an outcome at least as good as a synthetic nonabsorbable tape without the potential for sling erosion into adjacent structures, as it avoids the use of nonabsorbable material.

Laparoscopic cholecystectomy (LC) is commonly performed in patients who can pose technical challenges, such as obesity, prior surgery, and subsequent incisional hernias. A new technique, the subcostal trocar approach using four 5-mm with exclusive removal (STAUFFER) LC, was developed to diminish these impediments and is highly advantageous.A retrospective review was performed of medical records for 389 patients who underwent LC from June 2011 through December 2016. STAUFFER LC involves (1) steep patient positioning, (2) visualized 5-mm trocar entry in the right abdomen, (3) use of three additional right subcostal trocars, and (4) gallbladder extraction from the high right lateral trocar site. Patient characteristics, operative details, and outcomes were analyzed and compared.STAUFFER LC was used in 255 patients (65.6%), and standard four-trocar LC (SLC) was performed in 134 patients (34.4%). Overall indications for surgery included chronic cholecystitis (71.7%), acute cholecystitis (19.8%), polyp (2.3%), and other (5.9%). No significant differences were detected in comorbidities and American Society of Anesthesiologists classification between the two patient groups. More patients in the STAUFFER LC group had previous midline abdominal surgery (P = .06) and significantly higher body mass index (P = .03), and they required less operative time (P .001). No patient had an entry site injury. No significant difference was noted in morbidity. One patient required a second laparoscopic operation for bleeding. One patient with Crohn's disease and "hostile abdomen" had an enterocutaneous fistula that closed spontaneously. In the SLC group, trocar site hernia (TSH) developed in 3 patients.STAUFFER LC is widely applicable and effective, saving operative time and reducing the risk of TSH. It is especially advantageous for obese patients who have had previous surgery.

Purpose: To identify patterns and risk factors for rhegmatogenous retinal detachment (RD) in northern India. Methods: This was a retrospective study conducted at a tertiary care centre in northern India. 378 consecutive records of patient, operated between January 2011 to June 2012 were included for analysis. Clinical history, signs and risk factors of RD were evaluated. Comparison was done with available literature from other developing nations. Results: Mean age of the patients was 40.12 + 20.43 years (Range 12-85 years); 81% were male and half of the patients presented after 1 month of visual symptoms. Retinal breaks were discovered commonly in the temporal region, while no break was found in10% of the patients. PVR more than grade C was seen in a third of the patients. Prior surgery for cataract was found to be the most common identifiable risk factor for RD (40%). Bilateral RD was seen in 13% of the patients. Conclusion: Pseudophakia is the commonest risk factor for RD. If no retinal break is discovered pre operatively, the surgeon should seek a retinal break temporally during surgery. Bilateral RD is a serious concern for rural northern India, probably linked to delayed presentation.

Background: Prostatectomy is associated with short- and long-term morbidity, which includes attenuation of muscle function and deterioration of lean body mass. Physical function is a known predictor of morbidity and mortality, with initial evidence indicating that presurgical exercise is associated with fewer postsurgical complications and shorter hospitalization. The aim was to determine the feasibility of a supervised presurgical exercise program for prostate cancer (PCa) patients scheduled for prostatectomy. Methods: Ten men (68+6.4 years old) with localized PCa undertook a 6-week resistance and aerobic exercise program prior surgery. Training was undertaken twice weekly and patients were assessed at baseline, presurgery, and 6 weeks postsurgery. Outcome measures included muscle and physical performance, body composition, urinary incontinence and questionnaire. Results: Muscle strength increased by 7.5% to 24.3% ( P < .05) from baseline to presurgery but decreased to pretraining levels postsurgery, except for knee extensor strength ( P = .247). There were significant improvements ( P < .05) in the 6-m fast walk (9.3%), 400-m walk (7.4%), and chair rise (12.3%) at presurgery. Following surgery, improvements in physical performance were maintained. There was no change in lean or fat mass prior to surgery, but lean mass declined by 2.7 kg ( P = .014) following surgery. There were no adverse effects from the exercise program. Conclusions: Exercise undertaken prior to prostatectomy improved muscle and physical performance, with functional benefits maintained 6 weeks postsurgery. Presurgical exercise for PCa patients has the potential to facilitate recovery by improving physical reserve capacity, especially in men with poor muscle nd physical performance.

Aim: Compare radioembolization (Y90) and chemoembolization (CE) for the treatment of unresectable intrahepatic cholangiocarcinoma (UICC). Materials & methods: Institutional Review Board-approved, retrospective search was performed. Forty patients with UICC were treated with either Y90 (n = 25, 39 treatments) or CE (n = 15, 35 treatments). Comparative analysis was performed using Student's t and fisher-exact tests. Multivariable-logistic regression was also performed. Results: Median ages were 60 and 64 years for CE and Y90 groups, respectively (p = 0.798). Patient variables including age, Eastern Cooperative Oncology Group score, tumor burden, extra-hepatic disease, prior chemotherapy and prior surgery were similar between groups. Adverse events were similar in both groups (CE 20%, Y90 26%; p > 0.9). Overall response rate (CE 6%, Y90 4%; p > 0.9) and disease control rate (CE 46%, Y90 48%; p > 0.9) were statistically similar. Multilogistic regression did not identify any variables that correlated with disease control rate, including Eastern Cooperative Oncology Group score and tumor burden. Conclusion: Our observation shows that CE and Y90 display similar toxicity and disease control in the treatment of UICC.

1. More patients are willing to undergo a secondary mandibular contouring procedure due to dissatisfactory aesthetic results of the prior surgery. 2. Lack of a combined narrowing genioplasty procedure during mandibular contouring may cause a disproportionately broad chin. Additional chin narrowing surgery is required in such cases. 3. Excessive resection in the mandible angle region can result in an unnatural and hollow appearance. Implants may be used to correct the overly resected jaw contours. 4. Postoperative jawline asymmetry, irregular and uneven jaw contours and ‘secondary angle’ formation may result from technical faults during the surgery. Further bone contouring can improve these aesthetically unfavourable conditions.

Background Frameless image-guided radiosurgery (IGRS) is a safe and effective noninvasive treatment for trigeminal neuralgia (TN). This study evaluates the use of frameless IGRS to treat patients with refractory TN. Methods We reviewed the records of 20 patients diagnosed with TN who underwent frameless IGRS treatments between March 2012 and December 2013. Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. The initial setup uncertainty from simulation to treatment and the patient intrafraction uncertainty were measured. The median follow-up was 32 months. Results All patients' pain was BNI Grade IV or V before the frameless IGRS treatment. The mean intrafraction shift was 0.43 mm (0.28-0.76 mm), and the maximum intrafraction shift was 0.95 mm (0.53-1.99 mm). At last follow-up, 8 (40%) patients no longer required medications (BNI 1 or 2), 11 (55%) patients were pain free but required medication (BNI 3), and 1 (5%) patient had no pain relief (BNI 5). Patients who did not have prior surgery had a higher odds ratio for pain relief compared to patients who had prior surgery (14.9, P = 0.0408). Conclusions Frameless IGRS provides comparable dosimetric and clinical outcomes to frame-based SRS in a noninvasive fashion for patients with medically refractory TN.

Breast imaging can be hard to get right. You can take a beautiful set of images at 2,4,6,8,10 and 12 o'clock in both breasts, documenting normal tissue, and miss the cancer completely. You can simply “miss” the cancer in your survey, or perhaps misinterpret scanned tissue. Breast imaging is operator dependent, and you are the operator. Your ability to provide accurate assessment depends on knowing what you are looking for, your ability to interpret normal from abnormal, and documenting that information accurately. Performing breast ultrasound requires knowledge of anatomy, an understanding of the wide range of normal appearance, and the spectrum of benign, atypical, suspicious and malignant findings superimposed upon this wide range of normal. What can make breast ultrasound difficult includes patient factors such as age, mobility, breast size and density, and history prior surgery or treatment. Lack of information regarding these factors, and even patient demeanour, may also cause difficulty. The reason for breast examination is paramount: Is this a diagnostic examination or a screening study? Is there a history of prior benign, atypical or malignant pathology? Is there an MRI or mammography finding requiring correlation? Is there a clinical lump or symptom that is causing concern? Is the referring doctor's clinical concern the thing that is worrying this woman? Questions to consider: Do I need to ask this woman if she has any current lumps or concerns? Do I need to look at the mammogram? Do I need to look at prior studies? Do I need to interpret the lesion as benign, indeterminate or malignant before I take the image? Do I need to consider this woman who is connected to the breast I am scanning? The answer to all these questions is yes. This is particularly important when the imaging, and the women connected to the breasts you are imaging are “difficult”. Through a series of “difficult” case studies I hope to offer an approach to breast ultrasound imaging that will maximise your ability to provide meaningful, and accurate information that will benefit the woman who came in with the question– could it be cancer?

Background Ossification of the Achilles tendon is rare with most cases of ossification or calcification consisting of small, focal lesions. This pathology is usually predisposed by surgery, trauma, or other factors. Case description A case of extensive Achilles ossification and calcification, without prior surgery or trauma, is reported. Following removal of one of the largest ossific masses reported in the literature, measuring 11.0cm×2.5cm×2.0cm with additional 6.5cm calcifications, surgical reconstruction was required. Purpose and clinical relevance The objective of this report was to describe an unusual case of Achilles tendon ossification and calcification that occurred without the presence of predisposing factors. When a large gap is present after removal of the ossification, direct repair may be impossible and V-Y lengthening plus flexor hallucis longus (FHL) transfer is a viable option for pain relief and return to function.

Background We used intraoperative neuromonitoring to define the stages of the Latarjet procedure during which the nerves are at greatest risk. Methods Thirty-four patients with a mean age of 28.4 years were included. The Latarjet procedure was divided into 9 defined stages. Bilateral median and ulnar somatosensory evoked responses and transcranial motor evoked potentials from all arm myotomes were continuously monitored. A "nerve alert" was defined as averaged 50% amplitude attenuation or 10% latency prolongation of ipsilateral somatosensory evoked responses and transcranial motor evoked potentials. For each nerve alert, the surgeon altered retractor placement, and if there was no response to this, the position of the operative extremity was then changed. Results Of 34 patients, 26 (76.5%) had 45 separate nerve alert episodes. The most common stages of the procedure for a nerve alert to occur were glenoid exposure and graft insertion. The axillary nerve was involved in 35 alerts; the musculocutaneous nerve, in 22. Of the 34 patients, 7 (20.6%) had a clinically detectable nerve deficit postoperatively, all correlated with an intraoperative nerve alert. All cases involved the axillary nerve, and all resolved completely from 28 to 165 days postoperatively. Prior surgery and body mass index were not predictive of a neurologic deficit postoperatively. However, total operative time ( P = .042) and duration of the stage of the procedure in which the concordant nerve alert occurred ( P = .010) were statistically significant predictors of a postoperative nerve deficit. Conclusions The nerves, in particular the axillary and musculocutaneous nerves, are at risk during the Latarjet procedure, especially during glenoid exposure and graft insertion.

Background. Laparoscopic ureterolithotomy has become an alternative to open surgery for removing large stones that is not amenable to endoscopic treatment. In most of the published literature, laparoscopic ap- proach for lower ureteric stone is described to be less successful than middle and upper ureter. Identifica- tion in anatomical landmarks and exposing the distal ureter has been the major boundaries in establishing laparoscopic distal ureteral stone. We hope to provide clarity and feasibility that may increase our knowledge in laparoscopic ureterolithotomy for large distal ureteral stone. Aim. The obbjective is to share our experience in laparoscopic ureterolithotomy for large distal ureteric stone with transperitoneal approach Methods. A 37 years old male has been diagnosed with a right hydronephrosis due to proximal ureterolithiasis and stone at left calyx inferior, first and stone migrated to right distal ureter on 12 hours prior surgery. He underwent laparoscopic ureterolithotomy with transperitoneal approach. Results. We successfully perform laparoscopic ureterolithotomy with transperitoneal approach on a 37 y.o male patient who diagnosed with a a right hydronephrosis due to distal ureterolithiasis and stone at left calyx inferior. Duration of operation was 45 minutes. Patient was discharged at 2nd postoperative day without any complications. Conclusion. A Transperitoneal laparoscopic ureterolithotomy for distal ureteric stone is a safe and feasible technique that should be an options on every patients who plan to undergo distal ureterolithotomy especially large stone

Reconstruction of the ascending portion of the mandible, including the angle, ramus, and condyle, can be a challenging surgical problem. Many treatment options are available, but no single procedure has been able to restore long-term form and function in every case. Currently, autologous nonvascularized bone grafts are the most common treatment, with the costochondral graft as the historic leader. Nonvascularized grafts can often restore vertical height and normal function but may face the challenge of long-term durability secondary to bone resorption. Emerging techniques in microvascular surgery may offer an alternative approach with the benefits of resistance to resorption and infection by maintaining a viable blood supply to the graft. Vascularized grafts may thus be used to full advantage in cases where prior surgery, scarring, disrupted vasculature, or radiation damage may compromise the long-term surgical success of a nonvascularized graft. This article reviews the literature and summarizes key points regarding nonvascularized and vascularized treatment modalities for reconstruction of the ascending mandible. In addition, we present the use of the femoral medial epicondyle free flap based on the descending genicular vascular pedicle as a novel reconstruction of the ascending portion of the mandible with minimal donor-site morbidity. Knowledge of all available options will aid the surgeon in achieving the optimal reconstruction for their patient and improve long-term outcomes.

Introduction: The best method of primary trocar insertion in laparoscopy remains controversial. There are advocates for both initial Veress needle insertion as well as direct trocar insertion. Aim of the study: This study was carried out to find out the complication rate of direct trocar insertion as a method of laparoscopic entry and find out the learning curve of trainees in a structured fellowship programme. Methodology: Retrospective analysis was done over period of 5 years with a sample size of 2053 subjects. Results: 2053 laparoscopic surgeries were examined. Overall complication rate was 0.38%; subjects with previous abdominal surgery were found to have higher complication rate as compared to ones with no history of prior surgery. [0.46% and 0.35% respectively]. All trainees gained reasonable degree of confidence within 6 months. Conclusion: Direct trocar insertion is a safe method of laparoscopic entry, which can be taught to trainees with no prior laparoscopic experience, without an increase in entry complications. International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 Page : 51-54

527 Background: About 50% of patients undergoing post-chemotherapy retroperitoneal lymph node dissection (pcRPLND) are overtreated due to missing markers or valid prediction scores prior surgery. The potential of radiomics and machine learning applied on computed tomography (CT) imaging to predict the presence of viable tumor or teratoma in retroperitoneal lymph node metastases from germ cell tumor (GCT) patients prior to pcRPLND has not been explored. Therefore, we applied radiomics and machine learning to CT images of GCT patients prior to pcRPLND. Methods: Metastasized GCT patients who were treated with chemotherapy and received a contrast-enhanced CT prior to pcRPLND possessing complete clinical data were included in the study. Only lymph nodes which were identified in the CT images and correlated with the pathological findings (benign: necrosis / fibrosis vs. viable: viable tumor/ teratoma) were included. Lymph nodes identified in the CT images, were semiautomatically segmented and 93 radiographic features were analyzed. A linear support vector machine (SVM) algorithm was applied to analyze reproducible radiomics features. Additionally, a continuous reduction of the features analyzed was performed using Random Forest algorithms, as well as consecutive correlation and receiver operating curve analyzes. Results: Forty-two patients fulfilled the inclusion criteria and were included in the study. Total in these patients 96 lymph nodes were segmented on CT. Histologically, 41 lymph nodes were classified as viable tumors and 55 as benign. To train the SVM, 67 lymph nodes were randomly selected. Of the 93 radiomic features analyzed, 51 features were reproducible. Applying the trained algorithm to the remaining 29 lymph nodes resulted in a classification accuracy of 82% with a diagnostic sensitivity of 81% and a specificity of 83%. After multistep feature reduction, the three most important predictors for viable tumor achieved a sensitivity of 66% and a specificity of 78% when combined in a multivariate model. Conclusions: The applied radiomics model, solely based on CT images achieved a good sensitivity and specificity in predicting viable metastases.

A 40-year-old woman with no history of trauma or prior surgery presented to the emergency department with headache and left eye pain after nose blowing. Noncontrast maxillofacial computed tomography examination revealed an orbital floor fracture that ultimately required surgical repair. There are nontraumatic causes of orbital blowout fractures, and imaging should be obtained irrespective of trauma history.

UNLABELLED : Prior studies suggest that pelvic organ prolapse (POP) and stress urinary incontinence (SUI) may recur following surgery in 20% or more of patients. Despite these numbers, we have anecdotally found that some surgeons performing pelvic floor reconstruction feel their success rates exceed these figures. Based on our experience, we hypothesized that significant numbers of patients with recurrent POP or SUI following prior surgery do not return or notify their original surgeon of their recurrence. We also aimed to identify reasons why the patient was seeking care elsewhere. METHODS We investigated patients presenting to a tertiary referral center urogynecologic practice with recurrence after prior POP or SUI surgery over a 2-year period. Data were collected using an institutional review board-approved 15-item questionnaire and after 2 years were analyzed. RESULTS We found that 16 (31%) of 51 patients did not notify their primary surgeon of surgical failure. Of these patients, roughly half (9/16) did not return because of moving to a different area of the country, changing their insurance, or their prior physician retiring. Despite the surgical failures, of all patients presenting to our clinic, very few stated they had a poor relationship with their prior surgeon (6%); however, a large majority (63%) did not think that their primary surgeon could fix their problem. CONCLUSIONS Roughly one third of patients who suffer from recurrence after POP or SUI surgery do not notify their original surgeon. This may artificially inflate a clinician's perceived success rate of pelvic floor repair.

Purpose: The purpose was to evaluate the results of bilateral lateral rectus (BLR) recession which is based on augmented surgical amounts of classical surgical table of Parks' for basic and pseudo-divergence excess type intermittent exotropia [X(T)]. Materials and Methods: Patients with X(T) operated by the same surgeon and followed-up for at least 6 months were included. Patients with prior surgery, neurobehavioral and musculoskeletal conditions, strabismus different from that mentioned above X(T) were excluded. All the patients received BLR only. The amount of the recession was increased by the amount needed to correct 5 prism diopters (PD) more X(T) than what was measured. After the operation, 1 st week, 2 nd and 6 months measurements were recorded. The patients were grouped according to their 1 st week (3-7 days) postoperative examination as: >10 PD esotropia (Group 1), ≤10 PD esotropia (Group 2), exotropia (Group 3), and orthotropic (Group 4), respectively. Final surgical outcomes were classified as "good" (≤10 PD exotropia and ≤5 PD esotropia), "recurrence" (>10 PD exotropia) and "overcorrected" (>5 esotropia). Results: Thirty-seven patients were included. The mean age was 6.78 ± 2.87 years (range: 2-12 years). Mean preoperative deviation was 29.72 ± 8.07 PD (range: 15-45 PD) at distance and 20.94 ± 11.65 PD (range: 10-45 PD) at near (P < 0.0001). There were 21 (56.8%) patients in Group 1, 9 (24.3%) patients in Group 2, 1 (2.7%) patient in Group 3 and 6 (16.2%) patients in Group 4. Initial esotropia was achieved in 30 (30/37) of the patients. Twenty-eight of them had good results at the end of the 6 months. Overall "motor surgical" success rate was found to be 89.2% (33/37 patients), with 1 (2.7%) overcorrection and 3 (8.1%) recurrences at the end of the 6 months. Conclusion: This study demonstrated that early overcorrection of 10-20 PD after X(T) surgery can achieve acceptable motor outcomes in the first 6 months postoperative period.

The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.

Introduction Prolactinoma is the most frequent functioning pituitary adenoma. Most commonly occurs as microprolactinoma (less than 1 cm in size), which may be cured with medical therapy, but few long-term studies are available about optimal duration of treatment with dopamine agonists to ensure cure after drug discontinuation and its withdrawal without recurrence are do not report consistent results. Objective To establish criteria for cure of microprolactinoma with medical treatment and to analyze the potential predictors involved. Patients A retrospective study was conducted on 47 adult women with microprolactinoma followed up between 1975 and 2010; none of them had undergone prior surgery or radiotherapy, and all of them received treatment with a dopamine agonist for at least 4 years. They were divided into two groups for analysis: cured patients with at least 4 years with normal prolactin levels after drug discontinuation, and not cured patients. Results Cure was achieved in 57.4% of patients. Only age at diagnosis was a significant predictor: there were more young patients in the cured group and youngest patients needed less time to cure. Development of empty sella turcica or normal MRI was similar regarding time to cure. Conclusions Microprolactinoma may be cured with dopamine agonists, and life-long treatment is not required, although more than 10 years may be required to achieve cure, 11.6 ± 5.3 years in our experience.

Polymorphous low-grade adenocarcinoma (PLGA) is a rare malignancy most commonly seen in the minor salivary glands. First described in 1983, this entity has been recognized to have an indolent course with rare metastases or deaths. We describe our experience with 17 patients treated at our institution for PLGA from 1984 to 2012. All tumors were located in the oral cavity or soft palate. All patients were treated surgically, with the exception of one patient who declined therapy. No deaths or metastases have been identified in subsequent follow-up. Three patients in this series had undergone prior surgery up to 20 years previously and were treated for recurrences at our institution; no other recurrences have been noted. In summary, PLGA is best treated with wide excision to negative margins with excellent prognosis, but long-term follow-up is recommended given the propensity for late recurrences.

Management of scaphoid nonunion after failed surgery for acute scaphoid fracture presents a unique treatment challenge. Prior surgery complicates patient evaluation and increases the technical difficulty of future procedures. Healing of nonunion is crucial to prevent carpal collapse and progressive arthritis. A thorough workup is required to identify technical factors or treatment decisions that may have resulted in a poor outcome after initial fixation attempts. CT is particularly useful for characterizing nonunion and planning revision surgery. Several studies have described the use of bone grafts and fixation devices for scaphoid nonunion repair, including nonvascularized and vascularized bone grafts, screws, pins, and plates. Reliable rates of union have been achieved using nonvascularized bone graft supplemented with screw or wire fixation, particularly in the absence of osteonecrosis. Although vascularized grafts are more technically challenging, they improve the odds of union in the setting of osteonecrosis.

Importance The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. Objective To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. Design Retrospective review of a single surgeon’s rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. Setting Tertiary care academic health center. Participants Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. Main Outcomes and Measures Intraoperative findings, postoperative results. Results Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. Conclusions and Relevance Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting—including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts—can improve alar retraction. Level of Evidence 4.