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Background Reconstruction of the mutilated hand is one of the most difficult challenges for hand microsurgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore the hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction. Methods Between 1997 and 2018, 53 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes. Results In total, 173 digits were amputated from 53 patients (one patient suffered from bilateral hand injuries, so totally 54 hands). Sixty-eight digits underwent heterotopic digital replantation, 30 digits had orthotopic digital replantation, and 75 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 83.8% (57/68) and 86.7% (26/30), respectively (p = 1). Tripod grip was achieved in 83.3% (45/54) of patients following replantation and optional secondary reconstructive surgeries. Conclusion Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. The basic principles are to restore a functional thumb in the first instance, followed by at least two adjacent fingers against which the thumb can oppose. This method is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result.

Ian Jackson and Jack Fisher published one of the earliest reports on microsurgical applications for craniofacial patients in 1989. Since that time, applications of craniofacial surgery and microsurgery have significantly expanded and become more refined. However, there remain certain specific clinical problems in cleft and craniofacial surgery in which traditional craniofacial methods provide variable success or suboptimal outcomes. The purpose of the current study is to share our experience using an integrated approach of craniofacial and microsurgical methods to provide optimal surgical solutions to this complex patient population. The authors performed a retrospective review of 17 patients that utilized craniofacial microsurgery in setting of cleft and craniofacial syndromes performed by the senior author from July 2013 to July 2020. 22 free flaps were performed for 17 patients. The patient age at time of flap reconstruction ranged from 10 to 48 years (mean 21.4 years). There were 8 females and 9 males. There was one total flap loss. Based on our collective experience, the authors present a comprehensive algorithm for the role of microsurgical reconstruction in cleft and craniofacial patients. There are several situations in craniofacial surgery which traditional reconstructive methods require numerous operative interventions to achieve suitable outcomes. Craniofacial Microsurgery techniques can bring in new tissue and may prevent the need to manipulate scarred and multiply operated tissues. The craniofacial surgery team should not hesitate to apply microsurgical solutions to these situations for optimal results.

Background:. The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction. Methods:. A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated. Results:. The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different. Conclusions:. We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.

Background:. Skin cancer incidence has been rapidly increasing over the past 2 decades, and the resulting defects from excision have significant aesthetic and functional implications. In particular, wound coverage for large scalp and forehead defects with calvarial exposure can lead to hairline distortion, contour irregularities, and alopecia. We describe a 2-stage technique for scalp reconstruction, which preserves the normal hairline, covers exposed bone with vascularized tissue, and restores an aesthetic soft-tissue contour. Methods:. This is a retrospective case series of 13 adults with ages ranging from 50 to 89 years. All patients underwent Mohs surgery on the forehead or scalp between July 2014 and April 2017. Patients underwent a 2-staged reconstruction with an initial pericranial flap and dermal substitute placement followed by the placement of a split-thickness skin graft within 4–6 weeks. Results:. Over a 3-year period, 13 patients had successful reconstruction of the scalp defect without alteration of the hairline or contour irregularity. Two patients had minor complications after the first-stage procedure with successful aesthetic reconstruction. Conclusions:. Full-thickness defects of the scalp and forehead with bone exposure provide a reconstructive challenge for plastic surgeons. Reconstructive algorithms continue to evolve and should be tailored to best suit patients’ needs and medial comorbidities. Two-staged reconstruction with local pericranial flap provides a safe and efficacious reconstruction that minimizes hairline distortion, contour irregularity, and donor site morbidity.

Introduction Implant-based (alloplastic) breast reconstruction is the most common method for breast reconstruction. Patients frequently choose this method because of quicker surgery and recovery as compared with autologous reconstruction.

The internal mammary artery perforator (IMAP) flap can be used as either loco-regional or free flap, and provides thin flexible coverage for defects of the chest wall and cervical regions. In this report, we present a bilateral mastectomy case in which the left mastectomy defect was closed with an IMAP propeller flap harvested from the right breast. Our patient with a history of left breast conservation therapy was diagnosed invasive ductal carcinoma in her left breast 14 years later. On physical examination, the patient's left breast displayed the stigmata of radiotherapy including dark discoloration and firmness to palpation, compared to contralateral pendulous breast. After bilateral mastectomy, an IMAP flap with a size of 26 cm × 11 cm was harvested from right chest and was transposed 180 degrees clockwise in a propeller fashion to the left mastectomy defect without any tension. The flap survived without any complication and the patient was free of recurrence or metastases during the follow-up of 18 months. The patient was satisfied with the outcome. IMAP propeller flap could be harvested safely to the anterior axillary fold in the subcutaneous fat plane. It may provide a large skin paddle especially in large breasted women. © 2016 Wiley Periodicals, Inc. Microsurgery 36:507-510, 2016.

The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions.Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and concomitant vascular lesions treated with vascularized lymph node flaps were reviewed. The patients had vascular interventions discovered during workup for lymphedema surgery. Outcomes were assessed using circumferential difference (CD) and circumferential reduction rate (CRR) at 12-month and final follow-up visits.Vascular lesions (n = 15) included proximal arterial occlusion ( n = 1), vascular malformation ( n = 2), and proximal venous compression/stenosis ( n = 12). Concomitant vascular lesions had an incidence of 15.8% in patients that underwent vascularized lymph node transfers (VLNTs). We had 100% VLNT survival rate and average number of episodes of cellulitis after VLNTs decreased significantly ( p 0.05). The CRR for the below knee/elbow measurement at 12-months follow-up was significantly higher for patients that underwent vascular intervention for venous lesions before VLNT instead of concurrently or after (23.7% vs 12.2%, P = 0.23). Final mean CRR was 23.7% and 12.2% respectively.Preoperative workup of concomitant vascular lesions is important for lymphedema management. We suggest appropriate vascular intervention should be done prior to VLNT to maximize the short-term and long-term outcomes.

Achieving nipple reconstruction that maintains projection over the long term can be challenging for the reconstructive breast surgeon. In the Taiwanese patient population, the normal breast usually has a well-projected nipple on a small areolar footprint; therefore, maintenance of nipple projection is a paramount goal in our reconstructive efforts. We have adapted a technique that achieves this goal by utilizing a cartilage graft under the newly created nipple. The modified top hat flap design can be utilized in both implant-based and autologous breast reconstruction patients with suitable aesthetic results and a favorable complication profile. In long-term follow-up, approximately 26% of the initial projection is lost over time, but this can be accounted for by designing the flap with increased projection in mind to achieve a symmetric, pleasing result.

OBJECTIVE The double-opposing Z-plasty is an effective method of repairing the cleft palate due to its reorientation of the palatal musculature and lengthening of the soft palate. A technique for lengthening the palate with a single oral Z-plasty has also been described. The authors hypothesize that these 2 techniques have equivalent effects on palate length. METHODS A cadaver study was performed. Ten fresh adult cadaver heads were used.All palates were divided in the midline. In 5 specimens, a modified double-opposing Z-plasty technique was used; 5 other specimens underwent an oral Z-plasty with a straight-line repair of the nasal mucosa. In both groups, the levator veli palatini muscles were separately dissected and reapproximated with an intravelar veloplasty. The velar length, defined in this study as the distance from the posterior nasal spine to the tip of uvula, was measured before and after the surgical procedure. RESULTS The double-opposing Z-plasty produced a mean increase of 1.0 ± 0.6 cm in velar length (P = 0.023). The single Z-plasty repair resulted in a mean gain of 1.1 ± 0.3 cm (P = 0.001). There was no difference in change in palate length between the 2 procedures (P = 0.941), and no difference in the percentage of soft palate lengthening (24% vs 29%, respectively; P = 0.565). CONCLUSIONS A single oral Z -plasty provides palatal lengthening equivalent to that of a double-opposing Z-plasty procedure.

Introduction Optimal design of PAP flaps requires precise perforator mapping. In a systematic review, Doppler ultrasonography demonstrated the highest sensitivity and positive predictive value (PPV). We present a prospective study of PAP flap design comparing PDU, handheld Doppler (HHD), and clinical findings. Methods From May to July 2016, 12 head and neck cancer patients receiving PAP flaps were examined with PDU and HHD. We used PDU to evaluate number, course, emergence point, peak systolic velocity (PSV), and arterial diameter of perforators. PDU skin markings were measured in relation to the groin and gracilis. Distances to the adjacent HHD marking were determined. Diagnostic results were compared with intraoperative findings. Results All perforators identified with PDU were confirmed intraoperatively. No sizable perforators found surgically were missed by PDU. Detecting perforators with diameters of ≧0.5 mm, false-negative rate of PDU was zero percent, sensitivity was 100%. Musculocutaneous courses were identified in all perforators and sensitivity of PDU was 96.7%. Arterial diameter was overestimated by PDU (1.49 ± 0.39 vs. 0.75 ± 0.31 mm, P > .05). PSV at the emergence point was 24.5 ± 11.9 cm/s. Average distance from the emergence point to the PDU marking was 2.45 ± 1.90 mm (0–6 mm). The PPV of PDU was calculated at 93.10%. Mean distance from the HHD to the PDU markings was 20.76 ± 16.5 mm (1–70 mm). Assuming PDU findings demonstrated the true anatomy, sensitivity of HHD was calculated with 89.7%, and PPV was 66.7%. All PAP flaps were successful, only minor revisions were needed. Conclusions PDU facilitated PAP flap design in all cases and offers a precise, non-invasive diagnostic tool for flap planning.

Summary Background The Ten Test, first described in 1997 by Strauch et al., is a simple, rapid, reliable and sensitive method to evaluate hand sensibility in adults. In this study, we validated its use in children. Methods We asked patients to rate sensibility elicited by a light moving touch on the palmar surface of digits in reference to sensibility elicited by the same touch in a digit confirmed as normal. Results A total of 73 subjects (age range: 1–12 years) were tested. Patients under age 5 years were significantly less likely to complete the test. The kappa statistic for the Ten Test in nine subjects, each tested separately by two examiners, demonstrated very strong inter-observer reliability (kappa=1.0, p Conclusions The Ten Test is a simple, validated, non-threatening method to evaluate hand sensibility in children and adolescents. We recommend its clinical use in patients age 5 years and older.

Nerve injuries from missile and gunshot wounds often produce significant disability, and their management is controversial. The role of the surgeon in cases of missile wounds with neurologic deficits is not well defined. Enhancing the trauma team’s ability to recognize treatable nerve injuries will lead to improved outcomes. Further, raising awareness of the time-sensitive nature of these injuries will also improve results in these cases. We reviewed a consecutive series of 17 pediatric patients with peripheral nerve injuries caused by missile and gunshot wounds in a tertiary care children’s hospital. We examined the indications for surgery, presence of associated injuries, mechanisms of injury, demographic characteristics and clinical outcomes. Urban victims were significantly more likely to have been intentionally assaulted than rural or suburban victims and they were also less likely to have completed follow-up care. High-energy weapons were more likely to require surgery compared with low-energy weapons. Patients presenting with tendon injuries were more likely to have a high-grade nerve injury requiring surgery. Patients presenting with tendon lacerations or high-energy mechanisms were significantly more likely to require surgery. Early exploration should be undertaken in cases where transection is likely to have occurred. Early decompression of common entrapment sites distal to repairs or injuries should be performed. Because follow-up is poor in this population, treatment should be prompt and thorough.

Intraneural perineurioma is a benign peripheral nerve sheath tumor of perineurial cell origin. We present the case of an intraneural perineurioma of the median nerve in a 23-year-old woman which posed a diagnostic challenge. Ultrasonography was found to be a quick, easy, and effective screening tool for identifying the source of the deficit followed by MRI to further elucidate the lesion. We discuss surgical management options for optimizing functional outcomes when addressing such lesions.

Summary Introduction The internal mammary vessels are frequently chosen as recipient vessels for breast free flap reconstruction. We have noticed that when using the internal mammary recipients that these patients have a propensity for tachycardia that was not previously observed. Our aim was to investigate the factors related to perioperative tachycardia in the microsurgical breast reconstruction population and to address whether use of the internal mammary system is a causative factor in tachycardia. Methods A retrospective chart review was conducted to identify patients who underwent abdominal-based microvascular breast reconstruction at the Washington University School of Medicine between 2002 and 2012 to identify the presence of tachycardia. After application of exclusion criteria, 76 microvascular abdominal-based free flap reconstructions were identified. The internal mammary (IM) TRAM group (n = 24) and the thoracodorsal (TD) TRAM group (n = 52) were compared. A binomial logistic regression was performed with the presence of tachycardia as the dependent variable. Results There was a higher incidence of tachycardia in the IM TRAM group when compared to the TD TRAM group (p = 0.004). The variables predictive of tachycardia in our logistic regression model were IMA recipient ( p = 0.04), need for transfusion ( p = 0.03), and presence of fever ( p = 0.01). Conclusion Our study reaffirms that there are several factors that are predictive of tachycardia in the setting of microvascular breast reconstruction. The IMA syndrome should be a recognized cause of tachycardia as using these recipient vessels are shown to be predictive of postoperative tachycardia as shown in our study.

The Furlow palatoplasty is commonly used for the correction of velopharyngeal insufficiency in cleft patients. An alternative procedure is introduced involving a single Z-plasty with overlapping intravelar veloplasty (Woo palatoplasty). This study compared the results of both techniques in the correction of velopharyngeal insufficiency.After institutional review board approval, a retrospective chart review was performed of all patients who had undergone secondary palatoplasty for the correction of velopharyngeal insufficiency. All nonsyndromic patients with imaging data were evaluated. Data elements included preoperative and postoperative velopharyngeal gap size and perceptual speech examination results.Fifty-two subjects were included: 30 subjects had undergone Furlow palatoplasty and 22 underwent Woo palatoplasty. Overall, a larger proportion of Woo (95 percent) than Furlow subjects (63 percent) did not require secondary surgery (p = 0.005). However, mean presurgery closure was significantly different between groups (p = 0.042). For a more refined assessment, only those with 80 percent or greater preoperative closure were evaluated. Successful results were achieved in 67 percent (10 of 15) in Furlow and in 100 percent (19 of 19) in Woo. Again, this finding was significant (p = 0.005). Linear regression analysis suggested a significant effect of cleft type (β = 2.3, p = 0.013) on closure after repair, with decreased closure in cases with isolated cleft palate.The Woo palatoplasty compared favorably with Furlow palatoplasty for correction of velopharyngeal insufficiency. The technique appears to be a viable alternative for palatal re-repair, especially in circumstances when Furlow palatoplasty cannot be performed.Therapeutic, III.

Objectives To evaluate whether nasal administration of budesonide in adults with chronic rhinosinusitis for 30 days suppresses adrenal function and to assess its clinical efficacy. Design An open-label prospective study. Setting Academic medical center. Patients We assessed adrenal function in 9 patients using the cosyntropin test before and after budesonide therapy. Intervention Budesonide respule therapy. Main Outcome Measure Scores from the Sino-Nasal Outcome Test–20 (SNOT-20), a tool for assessing rhinosinusitis health and quality of life, were used to assess efficacy of budesonide treatment. Results All of our patients showed adequate adrenal response to cosyntropin stimulation before and after the budesonide trial. The mean difference in SNOT-20 scores was −1 (95% confidence interval, −1.77 to −0.23; P = .02), indicating clinically significant improvement after therapy. Conclusion Our findings suggest that using budesonide nasal wash may be clinically effective in decreasing the symptoms of chronic rhinosinusitis and does so without suppression of the hypothalamic-pituitary-adrenal axis in patients with chronic rhinosinusitis.