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Purpose of Review: As one of the early hand transplant programs in the world, we are often asked to educate other programs on the lessons we have learned and on how to set up a successful hand transplantation program., Recent Findings: Two decades of global experience with vascularized composite allotransplantation (VCA) of the upper limb have demonstrated improved functional outcomes and quality of life for carefully screened patients. Despite initial reticence about VCA, over 30 patients in the USA have benefited from hand transplantation, with around 80% long-term successes. We have experience with four bilateral upper extremity patients who have undergone bilateral upper extremity allotransplants. This review article highlights our personal experience and lessons with respect to VCA team assembly, logistics, patient selection, perioperative planning, the operative procedure, and postoperative management., Summary: Continual learning and critical evaluation are crucial to maintaining a successful upper extremity VCA program. This will ensure that patients who stand to benefit most from this life-enhancing procedure are identified and are others optimized to achieve the best possible outcomes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Outcomes of pediatric facial reanimation beyond 10 years are not known. This cross-sectional study evaluated long-term surgical and patient-reported outcomes of adults who underwent smile reconstruction as children with either a cross-face nerve graft (CFNG) or masseter nerve transfer at least 10 years previously., Methods: Commissure excursion was quantified with FACE-Gram software at 3 time points: preoperatively, early postoperatively within 2 years, and at long-term follow-up. Patient-reported outcomes were evaluated with validated questionnaires (Facial Clinimetric Evaluation Scale, FACE-Q 1.0) and thematic analysis of semistructured interviews. Results are reported as median (interquartile range [IQR])., Results: A total of 42 patients were included (26 women and 16 men). Median long-term follow-up was 19.3 years (IQR, 8.8 years) for CFNG and 17.6 years (IQR, 5.8 years) for masseter nerve transfer. For both groups, commissure excursion increased significantly from preoperative to early postoperative time points and remained stable at long-term follow-up (P < 0.0001). Commissure excursion at long-term follow-up between the 2 groups was not significantly different (CFNG, 5.0 mm [IQR, 9.4 mm]; masseter nerve transfer, 8.4 mm [IQR, 4.1 mm]); P > 0.05). For patient-reported outcomes, median Facial Clinimetric Evaluation Scale score was 72 of 100, and 95% of respondents agreed with the statement "I am pleased with the result" on the FACE-Q 1.0. Overall quality of life was rated at 7 of 10 or greater by 97% of participants, and all participants would recommend the surgery to other children., Conclusions: Pediatric facial reanimation with CFNG or masseter nerve transfer reliably improves commissure excursion with longevity beyond 10 years. Adult patients report overall high satisfaction and social functioning., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Purpose: Professional achievement awards are an important factor in recruitment, promotion, and faculty review within academic institutions. Studies have shown that subconscious, gender-based assumptions of individuals and their work in traditionally male-dominated fields lead to more positive evaluations of men than women, a phenomenon present among scientific and medical award committees. This study examined gender representation among recipients of major North American plastic surgery society awards over the last 50 years. Methods: Recipient lists of major achievement awards bestowed by ten American and Canadian plastic surgery societies between 1970 and 2020 were accessed online or by direct contact with the society. Awardee gender, institution affiliation, graduation year, fellowship status, and additional major awards received were recorded. Comparisons were made between gender representation among society presidents, board membership, general society memberships, attending physicians, and plastic surgery residency enrolment. Results: Thirty-two major awards given by ten plastic surgery societies were included. Six hundred and twenty-five awards were conferred, of which 47 recipients were female (7.5%). Of the 121 individuals that received multiple major awards, 8 were female. Two-thirds of female awardees (72%) were clinical plastic surgeons and the remainder were scientists. Over the past 50 years, there has been a gradual increase in the proportion of female award winners. Conclusions: Despite a gradual increase in the proportion of female awardees in major plastic surgery societies, female plastic surgeons remain underrepresented among awardees, with less than 10% of major awards conferred to females., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2023 The Author(s).)

Vascularized composite allotransplantation (VCA) of the upper extremity is an established restorative procedure for selected patients with acquired upper limb loss. The majority of upper limb VCAs performed worldwide have been for victims of various forms of trauma. However, in the developed world, amputation following severe sepsis seems to be an increasingly common indication for referral to hand transplant programs. Unlike trauma patients with isolated limb injuries, patients with amputations as a complication of sepsis have survived through a state of global tissue hypoperfusion and multisystem organ failure with severe, enduring effects on the entire body's physiology. This article reviews the unique considerations for VCA candidacy in postsepsis patients with upper limb amputation. These insights may also be relevant to postsepsis patients undergoing other forms of transplantation or to VCA patients requiring additional future solid organ transplants., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting., Methods: A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting., Results: Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion., Conclusion: Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Learning Objectives: After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation., Summary: Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The impact of patient-specific psychosocial factors on functional outcomes after upper-extremity (UE) vascularized composite allotransplantation (VCA) is poorly understood. The objective of this study was to identify relevant psychosocial predictors for success or failure of UE VCA in an Austrian cohort., Methods: A qualitative study was undertaken consisting of semi-structured interviews with UE VCA staff, transplanted patients, and close relatives. Participants were asked about their perceptions of factors that either favored or hindered a successful transplant outcome, including functional status before surgery, preparation for transplant, decision-making, rehabilitation and functional outcome after surgery, and family and social support. Interviews were conducted online and recorded with the consent of interviewees., Results: Four bilateral UE VCA patients, 7 healthcare professionals, and a sister of a patient participated in the study. Thematic analysis revealed the importance of an expert interdisciplinary team with adequate resources for patient selection. Psychosocial aspects of prospective candidates are crucial to evaluate as they contribute to success. Both patients and providers may be impacted by public perceptions of UE VCA. Functional outcomes are optimized with a life-long commitment to rehabilitation as well as close, ongoing provider involvement., Conclusion: Psychosocial factors are important elements in the assessment and follow-up care for UE VCA. To best capture psychosocial elements of care, protocols must be individualized, patient-centered, and interdisciplinary. Investigating psychosocial predictors and collecting outcomes is, thus, critical to justifying UE VCA as a medical intervention and to providing accurate and salient information to prospective candidates., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hummel, Zuo, Talbot, Zimmerman, Katz, Kinsley and Kumnig.)

Background: Chronic rhinosinusitis (CRS) is a common inflammatory disease in otolaryngology, mainly manifested as nasal congestion, nasal discharge, facial pain/pressure, and smell disorder. CRS with nasal polyps (CRSwNP), an important phenotype of CRS, has a high recurrence rate even after receiving corticosteroids and/or functional endoscopic sinus surgery. In recent years, clinicians have focused on the application of biological agents in CRSwNP. However, it has not reached a consensus on the timing and selection of biologics for the treatment of CRS so far., Summary: We reviewed the previous studies of biologics in CRS and summarized the indications, contraindications, efficacy assessment, prognosis, and adverse effects of biologics. Also, we evaluated the treatment response and adverse reactions of dupilumab, omalizumab, and mepolizumab in the management of CRS and made recommendations., Key Messages: Dupilumab, omalizumab, and mepolizumab have been approved for the treatment of CRSwNP by the US Food and Drug Administration. Type 2 and eosinophilic inflammation, need for systemic steroids or contraindication to systemic steroids, significantly impaired quality of life, anosmia, and comorbid asthma are required for the use of biologics. Based on current evidence, dupilumab has the prominent advantage in improving quality of life and reducing the risk of comorbid asthma in CRSwNP among the approved monoclonal antibodies. Most patients tolerate biological agents well in general with few major or severe adverse effects. Biologics have provided more options for severe uncontrolled CRSwNP patients or patients who refuse to have surgery. In the future, more novel biologics will be assessed in high-quality clinical trials and applied clinically., (© 2023 S. Karger AG, Basel.)

Background: Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of facial paralysis in patients with craniofacial microsomia and outcomes after free functioning muscle transfer for dynamic smile reconstruction., Methods: A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software., Results: This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent) affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent smile reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in lip symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes., Conclusions: The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To summarize the preliminary experience in the treatment of esthesioneuroblastoma (ENB) and to explore the effect of age, chemotherapy, modified Kadish stage and pathological grade on the prognosis of ENB. Methods: The clinical data of 87 ENB patients from the First Affiliated Hospital of Sun Yat-sen University and Sun Yat-sen University Cancer Center between June 2002 and November 2017 were retrospectively analyzed. The modified Kadish stage was used to evaluate the extent of the lesions, and the Hyams grading system was used for pathological grading. The patients were followed up regularly to evaluate the recurrence and metastasis of the tumor. Cox proportional hazard model was used for univariate and multivariate analyses. Prognostic factors with P <0.05 in univariate analysis were included in multivariate analysis. After controlling the confounding factors, the model coefficients were used to calculate the hazard ratio (HR) and 95% confidence interval (CI). Results: The median follow-up time of ENB patients was 29 months, and the 5-year overall survival rate was 39.3%. In univariate analysis, age, chemotherapy, modified Kadish stage and pathology grade were independent predictors of overall survival, while gender, radiotherapy and surgery were not prognostic factors. Multivariate analysis showed that modified Kadish stage and pathology grade were independent predictors of overall survival rate after excluding confounding factors. Conclusions: Age, chemotherapy, modified Kadish stage and pathological grade are taking important role in the overall survival rate of patients with ENB. Modified Kadish stage and pathological grade are independent predictors of overall survival rate.

The application of scaffold-based stem cell transplantation to enhance peripheral nerve regeneration has great potential. Recently, the neuroregenerative potential of tacrolimus (a U.S. Food and Drug Administration-approved immunosuppressant) has been explored. In this study, a fibrin gel-based drug delivery system for sustained and localized tacrolimus release was combined with rat adipose-derived mesenchymal stem cells (MSC) to investigate cell viability in vitro. Tacrolimus was encapsulated in poly(lactic-co-glycolic) acid (PLGA) microspheres and suspended in fibrin hydrogel, using concentrations of 0.01 and 100 ng/ml. Drug release over time was measured. MSCs were cultured in drug-released media collected at various days to mimic systemic exposure. MSCs were combined with (i) hydrogel only, (ii) empty PLGA microspheres in the hydrogel, (iii) 0.01, and (iv) 100 ng/ml of tacrolimus PLGA microspheres in the hydrogel. Stem cell presence and viability were evaluated. A sustained release of 100 ng/ml tacrolimus microspheres was observed for up to 35 days. Stem cell presence was confirmed and cell viability was observed up to 7 days, with no significant differences between groups. This study suggests that combined delivery of 100 ng/ml tacrolimus and MSCs in fibrin hydrogel does not result in cytotoxic effects and could be used to enhance peripheral nerve regeneration., (© 2021 Wiley Periodicals LLC.)

Objective: Nerve allografts offer many advantages in the reconstruction of peripheral nerve gaps: they retain their native microstructure, contain pro-regenerative Schwann cells, are widely available, and avoid donor site morbidity. Unfortunately, clinical use of nerve allografts is limited by the need for systemic immunosuppression and its adverse effects. To eliminate the toxicity of the systemic immunosuppressant FK506, we developed a local FK506 drug delivery system (DDS) to provide drug release over 28 days. The study objective was to investigate if the local FK506 DDS enhances nerve regeneration in a rodent model of nerve gap defect reconstruction with immunologically-disparate nerve allografts., Methods: In male Lewis rats, a common peroneal nerve gap defect was reconstructed with either a 20 mm nerve isograft from a donor Lewis rat or a 20 mm fresh, unprocessed nerve allograft from an immunologically incompatible donor ACI rat. After 4 weeks of survival, nerve regeneration was evaluated using retrograde neuronal labelling, quantitative histomorphometry, and serum cytokine profile., Results: Treatment with both systemic FK506 and the local FK506 DDS significantly improved motor and sensory neuronal regeneration, as well as histomorphometric indices including myelinated axon number. Rats with nerve allografts treated with either systemic or local FK506 had significantly reduced serum concentrations of the pro-inflammatory cytokine IL-12 compared to untreated vehicle control rats with nerve allografts. Serum FK506 levels were undetectable in rats with local FK506 DDS., Interpretation: The local FK506 DDS improved motor and sensory nerve regeneration through fresh nerve allografts to a level equal to that of either systemic FK506 or nerve isografting. This treatment may be clinically translatable in peripheral nerve reconstruction or vascularized composite allotransplantation., (Copyright © 2021. Published by Elsevier Inc.)

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: To preserve the future of surgical innovation, opportunities for surgical residents to receive structured research training are paramount. The objective of this article is to help surgical residents navigate a research fellowship by overviewing key topics such as choosing an area of focus and supervisor, applying for external funding, transitioning away from clinical duties, managing intellectual property, integrating family planning, and incorporating research experience into independent career development., Materials and Methods: Using the framework of the University of Toronto's graduate degree-awarding Surgeon-Scientist Training Program, the authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program., Results: Full-time research fellowships offer a unique opportunity for residents interested in an academic career. Such full-time research fellowships away from clinical duties allow surgical trainees to focus on developing key research competencies, including how to generate hypotheses, apply research methodology, gain experience presenting and publishing manuscripts, and ultimately apply these skills as independent investigators to improve patient and population health. Research fellowships may also be an opportunity to develop intellectual property or facilitate family planning. Practical tips are provided for the transition back into clinical training and how to effectively market one's research skills for career advancement., Conclusions: The authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program. By adhering to the principles highlighted in this article, residents will be able to successfully navigate a full-time research fellowship to optimize their intellectual development, maximize their academic productivity, and facilitate their transition into an independent investigator., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Peripheral nerve injuries are common and frequently result in incomplete functional recovery even with optimal surgical treatment. Permanent motor and sensory deficits are associated with significant patient morbidity and socioeconomic burden. Despite substantial research efforts to enhance peripheral nerve regeneration, few effective and clinically feasible treatment options have been found. One promising strategy is the use of low frequency electrical stimulation delivered perioperatively to an injured nerve at the time of surgical repair. Possibly through its effect of increasing intraneuronal cyclic AMP, perioperative electrical stimulation accelerates axon outgrowth, remyelination of regenerating axons, and reinnervation of end organs, even with delayed surgical intervention. Building on decades of experimental evidence in animal models, several recent, prospective, randomized clinical trials have affirmed electrical stimulation as a clinically translatable technique to enhance functional recovery in patients with peripheral nerve injuries requiring surgical treatment. This paper provides an updated review of the cellular physiology of electrical stimulation and its effects on axon regeneration, Level I evidence from recent prospective randomized clinical trials of electrical stimulation, and ongoing and future directions of research into electrical stimulation as a clinically feasible adjunct to surgical intervention in the treatment of patients with peripheral nerve injuries., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Inc.)

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery., (Copyright © 2019. Published by Elsevier Ltd.)

Peripheral nerve injuries (PNI) are common and frequently afflict otherwise healthy individuals after traumatic or iatrogenic events. Adjuvant therapies to improve functional outcomes after surgical repair of PNI have been investigated extensively in preclinical studies; however, to date, none have been clinically proven to have a notable therapeutic effect. FK506 (tacrolimus), a US Food and Drug Administration-approved systemic immunosuppressant, has demonstrated promising neuro-regenerative properties in both animal studies and clinical reports, but its adverse effects when systemically administered have precluded its broader applicability for patients with PNI. Recent advances in bioengineered drug delivery systems have made local FK506 delivery to a site of PNI an intriguing method of promoting peripheral nerve regeneration, with promising results in preclinical translational investigations. This review summarizes the preclinical and clinical evidence for FK506's beneficial effect in promoting peripheral nerve regeneration when administered systemically and locally., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Tendon adhesions and capsular contractures following trauma to the proximal interphalangeal joint (PIPJ) may significantly reduce hand function. Traditional, staged surgical management prioritizes restoration of PIPJ passive range of motion with joint release prior to restoration of active range of motion (AROM) with tenolysis. This is expensive and burdensome for patients. Our objective was to evaluate functional outcomes of combined PIPJ release and zone II flexor tenolysis. Methods: We retrospectively reviewed patients who underwent combined PIPJ release and flexor tenolysis. Replantation and tendon graft cases were excluded. Data were collected on pre- and postoperative AROM, total active motion (TAM), tip to distal palmar crease (DPC) distance, and grip strength. Functional outcomes were graded using the Boyes, American Society for Surgery of the Hand, and modified Strickland scores. Results: Twelve patients (9 men and 3 women, median age = 40 years) with a total of 15 digits underwent combined PIPJ release and flexor tenolysis a median of 10.1 months after injury. At a median follow-up of 4.0 months, there were significant improvements in median PIPJ AROM (15° to 70°), TAM (105° to 223°), tip to DPC distance (6.0 to 2.0 cm), and grip strength (35% to 54% of unaffected hand). Modified Strickland score was good in 46% of digits and excellent in 38%. There were no tendon ruptures, surgical site infections, or devascularized digits. Conclusion: Proximal interphalangeal joint stiffness is a challenging complication of hand trauma. Although a complete return to premorbid range of motion and function is rarely attained with surgery, improved outcomes may be consistently achieved with secondary combined PIPJ release and zone II flexor tenolysis.

Introduction: Facial paralysis impairs the mimetic functions of the facial musculature. In pediatric patients, free functioning muscle transfer neurotized with an intact contralateral facial nerve is the gold standard for smile reanimation. In response to requests from families of children with facial paralysis, the Division of Plastic and Reconstructive Surgery at the Hospital for Sick Children hosted an inaugural "Facial Paralysis Family Day." The objective was to create an opportunity for families to meet, exchange stories, and build support networks., Methods: This study was a quality improvement project to conduct a needs assessment and evaluate the feasibility and satisfaction of implementing a family support intervention for individuals living with facial paralysis., Results: The needs assessment demonstrated that families were most interested in advances in medicine, therapy and coping sessions and meeting other families. The post-event evaluation questionnaire indicated that attendees enjoyed the event, would attend again and found it highly valuable connecting and networking other families. It also indicated that key needs identified were addressed, with excellent ratings for the presentation discussing advances in medicine (100% rated "good" or "very good"), the therapy sessions (92% rated "good" or "very good") and the presentations by patients and their families (100% rated "good" or "very good.") DISCUSSION:: Two areas of improvement highlighted were elaborating further on medical advances and facilitating interactions between families. Overall, this event was well regarded and will likely be repeated at our institution and serve as a valuable resource for other hospitals planning to organize a similar event.

Nerve graft reconstruction of gap defects may result in poor clinical outcomes, particularly with long regeneration distances. Electrical stimulation (ES) of nerves may improve outcomes in such patients. A single session of ES at 20 Hz for 1 h significantly enhances axon regeneration in animals and human subjects after nerve crush or nerve transection and repair. The objectives of this study were to evaluate if ES enhances axon regeneration through nerve grafts and if there is added benefit of a second, delayed session of ES (serial ES) on axon regeneration as compared to a single session only of ES. In female rats, a gap defect was created in the hindlimb common peroneal (CP) nerve and immediately reconstructed with a 10 mm nerve autograft (Experiment 1) or a 20 mm nerve autograft (Experiment 2). In Experiment 1, rats were randomized to 1 h of CP nerve ES or sham stimulation. In Experiment 2, rats were randomized to control (sham ES + sham ES), single ES (ES + sham ES), or serial ES (ES + ES), which consisted of an initial 1 h session of either ES or sham stimulation of the CP nerve, followed by a second 1 h session of ES or sham stimulation of the CP nerve 4 weeks later. In both experiments, after a 6 week period of nerve regeneration, CP neurons that had regenerated axons distal to the autograft were retrograde labelled for enumeration, and the CP nerve distal to the autograft was harvested for histomorphometry. In Experiment 1, rats that received CP nerve ES had statistically significantly more motor (p < .05) and sensory (p < .05) neurons that regenerated axons distal to the 10 mm nerve autograft, with more myelinated axons on histomorphometry (p < .001). Similarly, in Experiment 2, significantly more motor (p < .01) and sensory (p < .05) neurons regenerated axons distal to the 20 mm nerve autograft after a single session or two sessions of CP nerve ES. There was no significant difference in the number of regenerated motor or sensory neurons between rats with 20 mm CP nerve autografts receiving either one or two sessions of CP nerve ES (p > .05). In conclusion, a single session of ES enhances axon regeneration following nerve autografting with no added effect of a second, delayed session of ES. These findings support previous studies in animals and humans of the robust effect of a single session of ES in promoting nerve regeneration following injury and repair., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Video recording of surgical procedures is an important tool for surgical education, performance enhancement, and error analysis. Technology for video recording open surgery, however, is limited. The objective of this article is to provide an overview of the available literature regarding the various technologies used for intraoperative video recording of open surgery. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using the MEDLINE, Cochrane Central, and EMBASE databases. Two authors independently screened the titles and abstracts of the retrieved articles, and those that satisfied the defined inclusion criteria were selected for a full-text review. A total of 2275 publications were initially identified, and 110 were included in the final review. The included articles were categorized based on type of article, surgical subspecialty, type and positioning of camera, and limitations identified with their use. The most common article type was primary-technical (29%), and the dominant specialties were general surgery (22%) and plastic surgery (18%). The most commonly cited camera used was the GoPro (30%) positioned in a head-mount configuration (60%). Commonly cited limitations included poor video quality, inadequate battery life, light overexposure, obstruction by surgical team members, and excessive motion. Open surgery remains the mainstay of many surgical specialties today, and technological innovation is absolutely critical to fulfill the unmet need for better video capture of open surgery. The findings of this article will be valuable for guiding future development of novel technology for this purpose.

Background: A substantial global inequality exists between surgical need and the availability of safe, affordable surgical care. Low- and middle-income countries have the greatest burden of untreated surgical disease and addressing this inequity is the goal of the Global Surgery movement. Reconstructive surgery is a fundamental component of Global Surgery as it is central to the appropriate treatment of trauma, burns, wounds, and congenital malformations. The objective of this study was to analyze the most frequently cited articles in the field of global reconstructive surgery to understand the main publication trends., Methods: The 25 most cited articles relating to global reconstructive surgery were identified from all available journals through the Web of Science online database. The following data were extracted from each included article: title, source journal, publication year, total citations, average citations per year, authors, main subject, reconstructive surgery subspecialty, country, and institution of origin., Results: The average number of citations per article was 21.7 (median, 19; range, 10-40). Most articles originated from the United States, and only 1 originated from a low-income country. The majority of the articles focused on cleft lip and palate (CLP) (72%), with few articles discussing burns or trauma. The main discussion themes were the quality of care provided in low- and middle-income countries both by local and visiting teams, the burden of diseases in relation to global reconstructive surgery, and the impact of surgical interventions economically and on patients., Conclusions: The number of research articles and citations related to global reconstructive surgery are limited. Despite having a lower incidence than burns or trauma, there is a preponderance of reports focusing on missions treating CLP. These findings suggest that more research funding could be invested in global reconstructive surgery for conditions other than CLP.

Prominent scars may remain around the border of a mature skin graft (SG) at the interface of the SG with normal skin. The border of a SG may be constructed by either exactly approximating (A) or slightly overlapping (O) the edge of the SG on the wound margin. The purpose of this study was to evaluate whether A or O affects the quality of the border scar of SGs applied to burn patients. This prospective study was a within-border design in which adult burn patients requiring SGs served as their own control. Half of each study border was fashioned using O and the immediately adjacent other half was made using A. We randomly assigned O or A to the proximal or distal halves of vertical borders and the medial and lateral halves of horizontal borders. Both halves of the study border were identically fixated with staples or sutures and were managed in the same fashion postoperatively. Blinded evaluations at 3, 6, and 12 months of O and A borders were performed using the Vancouver Scar Scale (VSS), the observer component of the Patient and Observer Scar Assessment Scale (POSAS), and a global binary assessment of which half of the study border "looked better." Blinded patients also rated each half of the study border with a 10-point Likert scale. Values are reported as the mean ± SD or median (interquartile range), as appropriate. There were 34 borders studied in 15 subjects (46.7% female, age 29 [22,57], % TBSA burn 9.7 ± 5.3, and no inhalation injuries). Study borders were constructed at 7 (5,11) days postburn, had a total length of 12 (9.3,14.5) cm, and all involved split thickness SGs of thickness 13 (12,14)/1000th of an inch. Sheet grafts were applied in 27% and meshed grafts in 73%. SGs were applied immediately after excision in 75% or after allografting in 25%. Border scars matured between 3 and 12 months with reductions in total VSS from 8 (7,8) to 4 (3,6) for O borders (P < .001) and from 8 (7,9) to 4 (1,6) for A borders (P < .001). However, there were no significant differences between O and A borders in total VSS at 3 months (P = .165), 6 months (P = .602), and 12 months (P = .358) or in total OSAS at 3 months (P = .681), 6 months (P = .890), or 12 months (P = .601). At 12 months, 60% of O borders and 40% of A borders were globally rated as "better" (P = .258). There were no significant differences in the patients' subjective ratings of the O and A borders at 3 months (P = .920), 6 months (P = .960), and 12 months (P = .66). The scar quality at the border of a skin graft does not appear to be affected by the surgical technique used to construct the border at the time of grafting., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Esthesioneuroblastoma(ENB) is a sinonasal rare tumor, and the assessment on the prognosis have not been used with on consensus, our study aims to set an accuracy indicator to predict the outcomes of ENB. Method: A retrospective review was performed on 31 ENB patients. We collected 31 patients with ENB and reviewed the clinical data and pathological slides; modified Kadish stages were evaluated by otolaryngologist and imaging specialist; Hyams grading system were confirmed by two pathologists, who reviewed and paid attention to the pathological characteristics of Hyams grading system. Finally, the relation among the clinical data, pathological features and clinical outcome of these 31 ENB were analyzed by Kaplan-Meier method. Result: The Hyams grading system and modified Kadish stage were considered together seemed to evaluate the prognosis of ENB more accurately, when the scores over 6 points, the patients had the poor prognosis with the mean median survival months of 24.67±32.22, compared with the scores under 6 and the final scores reached at 4, 5, 6, 7, 8, the tumor metastasis rates were 14.3%, 16.7%, 33.3%, 50.0%, 100.0% respectively. Conclusion: Taking the Hyams grading system and modified Kadish stage into consideration, which may evaluate the prognosis of ENB more accurately., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

The face is arguably the most unique and defining feature of the human body. From birth, humans are conditioned to perceive, interpret, and react to information conveyed by faces both familiar and unfamiliar. Although face recognition is routine for humans, only recently has it become possible for a computer to accurately recognize a human face in an image or video. With advances in artificial intelligence, image capture technology, and Internet connectivity, facial recognition technology has entered the forefront of personal and commercial technology. Plastic surgeons should be prepared to answer questions from patients about the fundamentals of facial recognition technology, and the potential effects of plastic surgery on facial recognition technology performance. This article provides an overview of facial recognition technology, describes its present applications, discusses its relevance within the field of plastic surgery, and provides recommendations for plastic surgeons to consider during preoperative discussions with patients.

Objective: To investigate the expression of 11β-hydroxysteroid dehydrogenase (11β-HSD) in polyps of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and its correlation with glucocorticoid sensitivity. Methods: The prospective study method was applied. Forty-three adult CRSwNP patients from Otorhinolaryngology Hospital, First Affiliated Hospital of Sun Yat-sen University between April 2016 and June 2017 were enrolled in this study. There were 19 males and 24 females with the age of (37.44±7.42) years old. The endoscopic scores by nasal Polyps Grading System before and after one-week prednisone treatment (0.5 mg/(kg·d)) were evaluated. The response of glucocorticoid by the total endoscopic scores was estimated. According to the patient's reduced nasal polyp endoscopic score, patients were devided into nasal polyps insensitive to glucocorticoids treatment group (insensitive group) and nasal polyp sensitive to glucocorticoids treatment group (sensitive group). The expression of 11β-HSD1, 11β-HSD2 in nasal polyps were measured by Real-time PCR (RT-PCR), Western Blot and immunohistochemisty. According to the clinical data, the Logistic regression models and receiver operation characteristics (ROC) curves were used to explore the predictor for glucocorticoid response in CRSwNP. Results: The expression of 11β-HSD1 and 11β-HSD1/11β-HSD2 was higher in sensitive group than that of insensitive group, while the expression of 11β-HSD2 was lower (rank average was 26.08 vs 16.33, 27.24 vs 14.72, 18.66 vs 26.64, Z value was -2.511, 0.323, -2.059, respectively, all P< 0.05). The endoscopic scores in CRSwNP group declined whereas the expression of 11β-HSD1/11β-HSD2 increased ( r= 0.528, P= 0.001), while the cutoff value of the ratio of 11β-HSD1/11β-HSD2 was 2.290 (sensitivity was 79.17%, specificity was 88.89%). Conclusions: There is a positive correlation between the response of glucocorticoid and the ratio of 11β-HSD1/11β-HSD2, which could be used as a marker in predicting the level of tissue response to glucocorticoid therapy in CRSwNP.

Objective: Securing a residency training position in plastic surgery is highly competitive each year with a limited quota of positions and numerous qualified applicants. Although previous studies have highlighted the importance of residency programs and applicants seeking a "good fit," it remains poorly understood what influences a medical student's impression and desire to train at a certain program over others. The objective of this cross-sectional study was to identify which specific potentially modifiable factors during elective rotations and program interviews were most important to Canadian medical students when ranking plastic surgery programs., Methods: An electronic survey with 42 questions was administered to Canadian final year medical students who applied through the 2017 Canadian Residency Match Service to the plastic surgery training program at the University of Toronto. The survey consisted of 7-point Likert scale questions related to demographics, general factors affecting impression of a plastic surgery program, and specific factors related to the elective and interview experiences. Survey responses were collected anonymously for analysis., Results: Twenty-three of 46 applicants completed the survey (50% response rate). The most important general factors affecting a medical student's impression and desire to train at a residency program were mentors at a specific program (weighted average, 6.39) and geographic location of a program (weighted average, 5.65). During elective rotations, the most important factors identified were overall impression of resident and staff collegiality (weighted average, 6.57), overall impression of resident happiness (weighted average, 6.52), and having a formal rotation-end debrief evaluation with the supervising staff (weighted average, 6.04). At program interviews, perceiving an atmosphere of collegiality (weighted average, 6.45) and opportunities to interact with residents and faculty at an organized social event (weighted average, 5.95) were considered of greatest importance., Conclusions: Current applicants to plastic surgery in Canada prioritize resident happiness, program collegiality, and meaningful faculty relationships, such as those with a mentor, when ranking residency programs. Although finding a mutually "good fit" between applicant and program will remain a major aim, these findings indicate the importance of certain tangible, potentially modifiable factors that affect how medical students ultimately perceive and rank plastic surgery programs.

Background: Cellulose powder (CP) has been reported as a safe and effective complementary treatment for allergic rhinitis (AR). Currently, CP has gained increasing application for clinical management worldwide, particularly in China. However, studies focusing on the effect of CP on normal human nasal epithelial cells (hNECs) and ciliary function are lacking. Here, we aimed to explore the adverse effects of CP on the activity and ciliary function of hNECs., Methods: We biopsied ethmoid sinus or middle turbinate tissues during surgical resection from control subjects who underwent endoscopic sinus surgery for diseases other than AR. Cells were isolated and passaged, followed by differentiation in an air-liquid interface (ALI). Flow cytometry and cell viability test (cell counting kit-8) were performed to detect the cytotoxicity of CP (effects on cell proliferation) on normal hNECs. By using the ALI culture model, we investigated the effects of CP on ciliary beat frequency (CBF)., Results: There was a significant reduction in hNEC count at high concentrations of CP (2.5 mg/mL) at days 3 and 7 (both p < 0.05). As the concentration increased, cell death increased progressively from day 3 to day 7. However, these effects were not evident at low concentrations (0.25 mg/mL, p > 0.05). High-dose CP (2.5 mg) significantly reduced the CBF (p < 0.05). At lower concentrations (0.25-2.5 mg/mL), CP initially increased but subsequently reduced the CBF of hNECs compared with control group., Conclusions: Cytotoxicity and the suppression of ciliary beat at high concentrations justify more prudent use of CP for the management of AR., (© 2018 S. Karger AG, Basel.)

Background: Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited., Methods: A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up., Results: Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years., Conclusions: Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes., Clinical Question/level of Evidence: Therapeutic, IV.

Objective: To explore the clinical features, diagnostic methods and therapeutic strategy of silent sinus syndrome (SSS). Methods: A retrospective study was made on eight SSS patients treated during 2013-2016 in Longgang ENT Hospital and Otorhinolaryngology Hospital of the First Affiliated Hospital of SUN Yat-sen University. The following clinical data, including demographic data, symptoms, history of trauma and surgery, signs, imaging examination, endoscopic surgery and postoperative outcomes, were analyzed to summarize the diagnosis and treatment experiences. Results: Eight SSS patients showed the following clinical features: the proportions of both sexes and sinus sides were 4 to 4; seven cases (7/8) were adult, with an average of (48.1±11.8)y; seven cases (7/8) had long history of trauma or surgery, with an average of (17.9±10.5)y; seven cases (7/8) cannot recall the exact course of SSS; six cases (6/8) had no nasal symptoms; eight cases (8/8) had unilateral ocular discomforts; eight cases (8/8) had signs of unilateral enophthalmos (2-5 mm), accompanied with hypoglobus; and by CT and MRI scanning, eight cases (8/8) showed the unilateral maxillary sinus outlet obstruction, sinus full opacification, sinus wall bony rarefaction, sinus wall contraction, sinus volume loss, and the ipsilateral orbital floor bowing descent and orbital volume increase. After treated by endoscopic sinus surgery and followed-up for one year, four cases were cured, and the other four improved; no intra- or post-operative complications occurred; and no individual need a two-stage orbital plastic reconstruction. Conclusions: SSS often develops in the unilateral maxillary sinus of adult patient with long history of trauma or surgery, but the nasal symptoms and signs are silent. Diagnostic for SSS depends on characteristic ocular sign and sinus CT imaging. Endoscopic sinus surgery helps to improve ocular and nasal signs and promote orbital self-reconstruction.

Prosthetic options for patients with proximal upper limb absence are limited. Current above-elbow prostheses may restore basic motor functions for crucial activities, but they are cumbersome to operate, lack sensory feedback, and are often abandoned. Targeted muscle reinnervation is a novel surgical procedure that enhances the ability of patients with above-elbow amputations to intuitively control a myoelectric prosthesis. By transferring multiple severed peripheral nerves to a robust target muscle, targeted muscle reinnervation restores physiologic continuity and enables more intuitive prosthetic control. Although reports have been limited to adults, targeted muscle reinnervation has great potential for application in a pediatric population with congenital or acquired proximal upper limb absence. In this review, the authors describe the rehabilitative challenges of proximal upper limb amputees and outline the objectives, techniques, and outcomes of targeted muscle reinnervation. The authors then discuss important considerations for adapting targeted muscle reinnervation to pediatric patients, including cause of upper limb absence, central plasticity, timing of prosthesis fitting, role of the family, surgical feasibility, and bioethical aspects. The authors believe that carefully screened school-age children and adolescents with bilateral proximal upper limb absence, and select adolescents with unilateral proximal upper limb absence, should be seriously considered for targeted muscle reinnervation performed by an experienced surgical and rehabilitation team.

Facial reanimation provides patients affected by chronic facial paralysis a chance to regain basic human functions such as emotional expression, verbal communication, and oral competence for eating and swallowing, but there is still no consensus as to the best way to measure surgical outcomes. We performed a literature review to investigate the different functional outcomes that surgeons use to evaluate facial function after reanimation surgery, focusing on outcomes other than facial expressions such as speech, oral competence, and patient quality of life/satisfaction. A total of 37 articles were reviewed, with the majority reporting outcomes through subjective facial expression ratings and only 15 dealing with other functional outcomes. In particular, outcomes related to oral competence and speech were reported inconsistently. Facial reanimation patients would benefit from a unified movement to create and validate through consensus, an outcomes reporting system incorporating not only facial expression, but also oral competence, speech, and patient-reported quality of life, to enable global patient assessment., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Learning Objectives: After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction., Summary: Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.

Background: Heart murmurs are common in children and may represent congenital or acquired cardiac pathology. Auscultation is challenging and many primary-care physicians lack the skill to differentiate innocent from pathologic murmurs. We sought to determine whether computer-aided auscultation (CardioscanTM) identifies which children require referral to a cardiologist., Methods: We consecutively enrolled children aged between 0 and 17 years with a murmur, innocent or pathologic, being evaluated in a tertiary-care cardiology clinic. Children being evaluated for the first time and patients with known cardiac pathology were eligible. We excluded children who had undergone cardiac surgery previously or were unable to sit still for auscultation. CardioscanTM auscultation was performed in a quiet room with the subject in the supine position. The sensitivity and specificity of a potentially pathologic murmur designation by CardioscanTM - that is, requiring referral - was determined using echocardiography as the reference standard., Results: We enrolled 126 subjects (44% female) with a median age of 1.7 years, with 93 (74%) having cardiac pathology. The sensitivity and specificity of a potentially pathologic murmur determination by CardioscanTM for identification of cardiac pathology were 83.9 and 30.3%, respectively, versus 75.0 and 71.4%, respectively, when limited to subjects with a heart rate of 50-120 beats per minute. The combination of a CardioscanTM potentially pathologic murmur designation or an abnormal electrocardiogram improved sensitivity to 93.5%, with no haemodynamically significant lesions missed., Conclusions: Sensitivity of CardioscanTM when interpreted in conjunction with an abnormal electrocardiogram was high, although specificity was poor. Re-evaluation of computer-aided auscultation will remain necessary as advances in this technology become available.

Patients with major ear deformities and associated compromise of the superficial temporal artery are poor candidates for autogenous ear reconstruction because of a tenuous ipsilateral temporoparietal fascial flap (TPFF). Osseointegrated prosthetic auricular reconstruction (OPAR) is an alternative to contralateral free TPFF microsurgical and autogenous reconstruction, but data on clinical outcomes are limited. The records of patients with ear loss or major deformity and a compromised ipsilateral TPFF who underwent OPAR from 1989 to 2013 were reviewed. Satisfaction was assessed using a questionnaire based on a 5 point Likert scale. Thirty-two patients (8 women, 24 men) with mean age 43.0 years (range, 10-70 years) underwent OPAR. The ipsilateral TPFF was compromised due to major trauma (13 patients), cancer extirpation (9), burn injury (4), previous harvest (4), arteriovenous malformation (1), or infection (1). All but 2 patients had an associated craniofacial defect, such as soft tissue deformity (87.5%), hearing loss (46.9%), or bony deformity (31.3%). The overall implant success rate was 88.6% at mean follow-up time of 7.6 years post-OPAR. Prosthesis wear averaged 12.2 hours/day and 6.6 days/week (80.5 hours/week). All 5 patients who experienced implant failures had received prior head and neck irradiation. With their prosthesis, 76.2% (16 patients) stated that their self-consciousness and self-esteem were "better" or "much better," whereas 85.7% (18 patients) stated that their self-image was "better" or "much better." All patients declared that they would undergo the treatment again. Osseointegrated prosthetic auricular reconstruction is a reliable option in this challenging population with high patient satisfaction. Patients with prior radiotherapy may have a higher chance of implant failure and would benefit from extended annual follow-up.

Purpose: Length-dependent polyneuropathy is common. Current electrophysiological methods cannot assess sensory nerve function proximal to the distal calf, limiting their utility in the quantification of severity of length-dependent polyneuropathy., Methods: The authors developed a novel electrophysiological approach for distal to proximal assessment of the sural nerve between the forefoot and the knee and tested it on 63 healthy young, middle-aged, and old adults., Results: It was feasible to elicit sensory nerve action potentials in the forefoot, ankle, and knee segments of the sural nerve in all subjects. Intraobserver (r = 0.87) and interobserver (r = 0.87) reliability were high. Sensory nerve action potential amplitudes were greatest at the ankle, followed by the knee and forefoot. Sensory nerve action potential amplitudes in the forefoot and ankle were significantly smaller in the old age group (>60 years) compared with the young age group (20-39 years) (P < 0.05). In contrast, neither age nor gender had a significant impact on sensory nerve action potential conduction velocities., Conclusions: The authors demonstrated that reliable electrophysiological recordings of the sural nerve as proximal as the knee are feasible. This novel technique may be useful in patients with length-dependent polyneuropathy to monitor progression and to evaluate treatment response.

Background: Post-surgical pyoderma gangrenosum (PSPG) presents as a rapidly expanding cutaneous ulcer at a site of surgery with potentially devastating consequences. We systematically reviewed the English and foreign language literature to identify risk factors for PSPG and propose a management strategy., Methods: A systematic review was completed in PubMed, Medline, Embase, and Cochrane Database for all published reports of PSPG from January 1946 to June 2013. We manually examined bibliographies for relevant references and used Google Translate for articles in foreign languages, including Italian, Japanese, German, Dutch, Turkish, Spanish, Chinese, Dutch, Russian, Portuguese, and Czech., Results: We identified 220 cases of PSPG (mean age 52.8 years, range 5-85 years). Thirty-seven patients (16.8%) had a history of pyoderma gangrenosum, nineteen (8.6%) had a hematologic disorder such as leukemia or lymphoma, thirteen (5.9%) had inflammatory bowel disease, and eight (3.6%) had rheumatoid arthritis. PSPG occurred most commonly after breast (25%), cardiothoracic (14%), abdominal (14%), and obstetric (13%) surgeries. The most common breast procedures were bilateral reduction mammoplasty (45%), breast reconstruction (25%), and lumpectomy or mastectomy (11%). Signs of wound complication occurred on average 7.0 days after surgery. Nineteen patients (8.6%) at risk for PSPG received perioperative corticosteroids during skin grafting or later surgeries with a favorable outcome., Conclusions: Patients with a history of pyoderma gangrenosum, rheumatoid arthritis, inflammatory bowel disease, or hematologic malignancy who are undergoing breast, cardiothoracic, or abdominal surgeries should be carefully observed for post-operative ulceration at incision sites. Debridement should not be performed before dermatologic consultation to assess for PSPG. Patients at risk of PSPG undergoing breast surgery may benefit from perioperative prednisone to prevent PSPG which can lead to destructive wound enlargement and significant scarring., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Marjolin's ulcer is an aggressive ulcerating cutaneous malignancy that may arise in chronically inflamed or traumatized skin. Frequently overlooked, this rare condition is classically associated with burn scars, with the process of malignant degeneration typically occurring over two to three decades. The most common histopathological pattern is squamous cell carcinoma; however, compared to typical squamous cell carcinomas, Marjolin's ulcers have an increased rate of metastasis. The correlation between radiotherapy for benign hypertrophic scarring and carcinogenesis is controversial, with few reports in the literature. We present a unique case of a 61 year old Caucasian male who was burned by scald at age 4, received radiotherapy for his post-burn hypertrophic scars, and later developed multiple Marjolin's ulcers on his left arm, chest, and right temporal scalp., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

Traumatic brachial plexus root avulsions are devastating injuries, and are complex and challenging to reconstruct. Double free muscle transfer using the gracilis muscles is a potentially effective method of restoring upper extremity function. The authors report on the first two patients treated using this technique in Canada. Both sustained traumatic brachial plexus root avulsion injuries resulting in a flail arm. In the first step of this two-stage procedure, a gracilis muscle was transferred to restore elbow flexion, and wrist and digit extension. Months later, the transfer of the second gracilis muscle was performed to enhance elbow flexion and to enable wrist and digit flexion. Postoperatively, both patients achieved Medical Research Council grade 4 elbow flexion, functional handgrip and were able to return to gainful employment. Patient satisfaction was high and active range of motion improved substantially. The authors' experience supports the use of this technique following severe brachial plexus injury.

The hand is an integral component of the human body, with an incredible spectrum of functionality. In addition to possessing gross and fine motor capabilities essential for physical survival, the hand is fundamental to social conventions, enabling greeting, grooming, artistic expression and syntactical communication. The loss of one or both hands is, thus, a devastating experience, requiring significant psychological support and physical rehabilitation. The majority of hand amputations occur in working-age males, most commonly as a result of work-related trauma or as casualties sustained during combat. For millennia, humans have used state-of-the-art technology to design clever devices to facilitate the reintegration of hand amputees into society. The present article provides a historical overview of the progress in replacing a missing hand, from early iron hands intended primarily for use in battle, to today's standard body-powered and myoelectric prostheses, to revolutionary advancements in the restoration of sensorimotor control with targeted reinnervation and hand transplantation.