Surgical Management of Extensor Digitorum Brevis Manus Anomaly with a Dorsal Ganglion Cyst.

Background The most common soft tissue tumor of the hand is the dorsal ganglion cyst and often is an indication for surgical excision. The differential diagnoses for dorsal hand masses include but are not limited to tenosynovitis, epidermoid cyst, abscess, lipoma, xanthoma, rheumatoid nodule, tophus, carpal boss, myositis ossificans, foreign body granuloma, neoplasm, and anomalous muscles. Case Description Our case report reflects the latter, a 33-year-old female who presented with a 3-year history of a symptomatic dorsal ganglion cyst of her left wrist. She is a female in her 30s, with progressive, worsening pain on wrist extension. Intraoperatively, it was determined that an anomalous extensor digitorum brevis manus (EDBM) was present and may have contributed to her pain and was excised. Literature Review The literature is sparse with the surgical management of EDBM. This case study aims to explore algorithms for managing simultaneous EDBM with a dorsal wrist ganglion, which is clinically relevant for any hand surgeon, when faced with a similar intra-operative management situation.

Intramedullary Metacarpal Screw Fracture Fixation: A Retrospective Review of the Rehabilitation Literature and an Illustrative Case Report With a Postoperative Therapy Protocol.

ABSTRACT: Intramedullary metacarpal screw fixation has shown promising results and quick functional recovery with the proper postoperative rehabilitation. The rehabilitative process after this procedure has not been compared across literature. A retrospective review of literature was used to recommend a therapy timeline, activity and recommendations to allow for proper postoperative rehabilitation for optimal results. An illustrative case report is presented to explain technique and outcomes.

Classification of Newborn Ear Malformations and their Treatment with the EarWell Infant Ear Correction System.

BACKGROUND: A single practice's treatment protocol and outcomes following molding therapy on newborn ear deformations and malformations with the EarWell Infant Ear Correction System were reviewed. A classification system for grading the severity of constricted ear malformations was created on the basis of anatomical findings. METHODS: A retrospective chart/photograph review of a consecutive series of infants treated with the EarWell System from 2011 to 2014 was undertaken. The infants were placed in either deformation or malformation groups. Three classes of malformation were identified. Data regarding treatment induction, duration of treatment, and quality of outcome were collected for all study patients. RESULTS: One hundred seventy-five infant ear malformations and 303 infant ear deformities were treated with the EarWell System. The average age at initiation of treatment was 12 days; the mean duration of treatment was 37 days. An average of six office visits was required. Treated malformations included constricted ears [172 ears (98 percent)] and cryptotia [three ears (2 percent)]. Cup ear (34 ears) was considered a constricted malformation, in contrast to the prominent ear deformity. Constricted ears were assigned to one of three classes, with each subsequent class indicating increasing severity: class I, 77 ears (45 percent); class II, 81 ears (47 percent); and class III, 14 ears (8 percent). Molding therapy with the EarWell System reduced the severity by an average of 1.2 points (p < 0.01). Complications included minor superficial excoriations and abrasions. CONCLUSION: The EarWell System was shown to be effective in eliminating or reducing the need for surgery in all but the most severe malformations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lateral Abdominal Wall Defects: The Importance of Anatomy and Technique for a Successful Repair.

Flank and lateral abdominal wall defects can be an extremely challenging phenomenon for surgeons to undertake. Their rarity and specific idiosyncrasies in regard to embryologic and anatomical characteristics must be taken into consideration when formulating an operative plan. We will discuss these cardinal points including technical recommendations by notable experts in the field to gain a better understanding in the diagnosis and treatment of this infrequent but morbid occurrence.

Management and Reconstruction in the Breast Cancer Patient With a Fungating T4b Tumor.

BACKGROUND: A subset of women with locally advanced breast cancer presented with fungating tumor mass eroding and infiltrating the surrounding breast skin (T4b breast cancers). These patients often have chronic pain, large open wounds, frequent infections, malodorous drainage, social isolation, and general debilitation that present enormous therapeutic challenges. Because of the advanced nature of the disease, palliation, while minimizing recovery time and maximizing quality of life, is essential. METHODS: From 2009 to 2014, a total of 12 consecutive patients underwent resection of fungating T4b breast tumors and subsequent chest wall reconstruction. Demographic, socioeconomic, and clinical data were collected retrospectively. RESULTS: Fifty percent of women had distant metastases at the time of reconstruction, and 17% of women presented to the emergency department in a hemodynamically unstable condition in either hemorrhagic shock or septic shock, necessitating delay of reconstruction for up to 1 week. Mean wound size for reconstruction was 473 cm(2). Reconstructive procedures included split-thickness skin grafting and thoracoepigastric advancement, latissimus dorsi, trapezius, and extended transverse and vertical rectus abdominis flaps. Postoperative survival ranged from 98 to 172 days (mean = 127 days), with 9 patients currently living. Seventy-five percent of patients had improved pain and reduced wound care needs after reconstruction. Postoperative reconstruction-specific complications occurred in 33% of cases, with 1 patient requiring a second operating room visit. CONCLUSIONS: Women with fungating T4b breast cancer tumors often present with metastatic disease and have significant need for pain and wound palliation. The reconstructive techniques performed are reliable, efficacious in palliating pain, and reducing wound care needs and have low complication rates.

The Epidemiology of Mandibular Fractures in the United States, Part 1: A Review of 13,142 Cases from the US National Trauma Data Bank.

PURPOSE: To date, no studies have analyzed the national demographics of mandibular fractures in the United States. This report is part 1 of a 2-part series characterizing the modern demographics, epidemiology, and outcomes of mandibular fractures in the United States. The purpose of this study was to characterize mandibular fractures in relation to age, gender, mechanism of injury, and anatomic location of fracture. MATERIAL AND METHODS: A retrospective cohort study was conducted using the National Trauma Data Bank (NTDB). The sample was derived from the population of hospitalized patients enrolled in the NTDB from 2001 to 2005 using mandibular fracture (International Classification of Diseases, Ninth Revision codes 802.21 through 802.39) as an inclusion criterion. Patient- and injury-related variables, including age, gender, anatomic location of fracture, and mechanism of injury, were analyzed by Fisher exact and χ(2) testing. RESULTS: A total of 13,142 patients with mandibular fractures from participating trauma centers were included in the study. Eighty percent of patients were male. Fracture distribution by age was roughly bell-shaped, with fractures occurring most frequently at 18 to 54 years of age. Mechanism of injury differed by gender, with men most often sustaining mandibular fracture from assault (49.1%), followed by motor vehicle accidents (MVAs; 25.4%) and falls (12.8%). Women most commonly sustained mandibular fracture from MVAs (53.7%), followed by assault (14.5%) and falls (23.7%). Falls were a significantly more common mechanism in patients who were at least 65 years old (P < .001). CONCLUSION: This study sought to characterize the largest, modern, population-based sample of mandibular fractures in the United States. Overall, men had a 4-fold higher incidence, but this distribution varied by age. Similarly, mechanism of injury varied across gender and age range. A better understanding of the influence of age and gender on mechanism of injury and anatomic site is of great clinical importance in the assessment, diagnosis, and treatment of traumatic mandibular fractures.

Local anesthetic use in tumescent liposuction: an American Society of Plastic Surgeons survey.

BACKGROUND: Current guidelines favor the use of lidocaine in liposuction wetting solutions. The use of bupivacaine as an alternative remains controversial despite reports of its use with safe and favorable outcomes suggesting faster postoperative recovery time secondary to improved pain control. The goals of this study were to determine the prevalence of bupivacaine use, examine liposuction practices of bupivacaine users, and elucidate opinions regarding bupivacaine use. METHODS: An online survey was distributed to 2500 randomly selected members of the American Society of Plastic Surgeons. Data were collected and analyzed with special attention toward the practice and opinions of bupivacaine use. RESULTS: The response rate of the survey met the average American Society of Plastic Surgeons online survey response rate at 12.8% (n=320). Respondents (7.2%; n=22) reported using bupivacaine in their wetting solutions (bupivacaine group) and provided a dosage range of 62.5 to 150 mg. Respondents (83.5%; n=254) reported using either lidocaine or prilocaine (no-bupivacaine group). There were no reports of bupivacaine toxicity in 2011. The demographic profile and liposuction practices of both groups were comparable. Although 36% of the no-bupivacaine group did not know or had no opinion on when it is appropriate to use bupivacaine in liposuction wetting solutions, 85% of this group has used bupivacaine for other clinical purposes. CONCLUSIONS: A review of 320 plastic surgeons' experiences revealed that 7% of respondents are using bupivacaine in their tumescent solutions with no reported cases of toxicity. Bupivacaine users differed dramatically only in their opinion regarding the safety of bupivacaine in tumescent liposuction. The recent studies suggesting better postoperative pain control with bupivacaine along with the proportion of respondents reporting bupivacaine use call for distinct guidelines on bupivacaine use in liposuction. Further studies, including a rigorous clinical trial documenting the safety and efficacy of bupivacaine when compared with lidocaine, would be warranted.

Does the application of incisional negative pressure therapy to high-risk wounds prevent surgical site complications? A systematic review.

PURPOSE: The application of incisional negative pressure wound therapy (INPWT) to clean, closed surgical incisions is a growing clinical practice. A systematic review was conducted to evaluate the effect of INPWT on surgical sites healing by primary intention. The primary outcomes of interest are incidence of complications (infection, dehiscence, seroma, hematoma, skin necrosis, or blistering). METHODS: Two independent reviewers performed a search of the Ovid MEDLINE and EMBASE databases from 2006 to 2012 for published articles. Supplemental searches were performed using reference lists and conference proceedings. Studies were selected for inclusion based on predetermined inclusion and exclusion criteria. Data extraction regarding study quality, demographic and clinical characteristics, and outcomes was performed independently, and data on the incidence of infection was combined using a fixed-effects meta-analysis model. RESULTS: Ten (5 randomized controlled trials and 5 observational) studies were included, which investigated the outcomes of 626 incisions on 610 patients. Six studies compared INPWT with sterile dry dressings (SDDs). The literature shows a significant decrease in rates of infection when using INPWT. RESULTS on dehiscence do show a decrease in some studies, but results are inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on seroma, hematoma, and skin necrosis. CONCLUSIONS: This systematic review shows possible evidence of a decrease in the incidence of infection with application of INPWT. Looking at other variables such as dehiscence, seroma, hematoma, and skin necrosis show no consistent data and suggest further studies in order for proper recommendations for INPWT.

Corticosteroid use in cosmetic plastic surgery.

BACKGROUND: Steroids have been used in cosmetic plastic surgery to reduce postoperative edema and ecchymosis. We performed a systematic review of the literature addressing postoperative steroid use after rhinoplasty. Due to a paucity of studies, a review of the literature was also performed for postoperative steroid use in rhytidectomy and body contouring surgery. METHODS: An exhaustive literature search was performed using: MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PubMed. A total of 12 articles were chosen to be included in the rhinoplasty systematic review. Cohen's kappa for level of agreement between the two reviewers was 1.0. Data recorded from each of the studies included: author, year, sample size, age, follow-up, statistical analyses, eyelid/edema assessment, significant findings, p values, and steroid regimens. A general review of the current rhytidectomy and body contouring literature associated with corticosteroids was performed as well. RESULTS: No statistically significant long-term reduction in postoperative edema or ecchymosis after rhinoplasty. Significant reductions were noted in the short term (<2 days). Review of the rhytidectomy literature described no significant decrease in postoperative edema or ecchymosis. Steroid use was noted to reduce postoperative nausea and vomiting when combined with other therapies in body contouring. CONCLUSIONS: Steroid use is not warranted in the postoperative period and only reduces transient edema and ecchymosis. A significant benefit for steroid use after rhytidectomy is not evident as well. Steroid use may benefit in postoperative nausea and vomiting.

Telomeres shorten at equivalent rates in somatic tissues of adults.

Telomere shortening in somatic tissues largely reflects stem cell replication. Previous human studies of telomere attrition were predominantly conducted on leukocytes. However, findings in leukocytes cannot be generalized to other tissues. Here we measure telomere length in leukocytes, skeletal muscle, skin and subcutaneous fat of 87 adults (aged 19-77 years). Telomeres are longest in muscle and shortest in leukocytes, yet are strongly correlated between tissues. Notably, the rates of telomere shortening are similar in the four tissues. We infer from these findings that differences in telomere length between proliferative (blood and skin) and minimally proliferative tissues (muscle and fat) are established during early life, and that in adulthood, stem cells of the four tissues replicate at a similar rate.

Distal urethral reconstruction with AlloDerm: a case report and review of the literature.

Reconstruction of large urethral defects is a complex problem for which no standardized surgical guidelines exist due to the lack of clinical trials demonstrating definitively the superiority of one technique over another. AlloDerm has been used in other surgical specialties with success, however, its utility in urologic surgery and, more specifically, for urethral reconstruction has been limited. In this case report, we demonstrate its application in a single-staged closure of a significant anterior urethral defect following distal penile necrosis secondary to an extruded penile prosthesis in a diabetic patient.

Effect of preoperative magnetic resonance imaging diagnosis of osteomyelitis on the surgical management and outcomes of pressure ulcers.

Despite advances in imaging technology, it is unclear whether preoperative MRI diagnosis of osteomyelitis influences surgical management and improves surgical outcome. The purpose of this retrospective study was to determine whether preoperative diagnosis of osteomyelitis by pelvic MRI influenced the surgical management of pressure sores and flap outcomes. The characteristics, pre- and intraoperative management, and surgical outcomes of the most recent flap surgery in 2 groups were compared: 26 patients diagnosed with osteomyelitis by preoperative MRI and 21 patients diagnosed by culture growth from an intraoperative bone specimen postoperatively. Patients with osteomyelitis diagnosed by MRI had 10 ulcer recurrences at the same site (39%) versus 6 (29%) among patients with osteomyelitis diagnosed by bone culture (odds ratio = 2.4, P = 0.22). We found that patients with a diagnostic preoperative MRI did not differ significantly in rates of antibiotic administration, ostectomy, dehiscence, revision, or infection.

Telomere dynamics in keloids.

OBJECTIVE: Little is known about telomere dynamics in keloids. As keloid formation is dependent on cell replication, in theory telomeres should be shorter in keloids than in normal skin. We examined this concept in the present study. METHODS: We measured by Southern blot analysis telomere length in keloids and in adjacent normal skin of 16 individuals. When available, we also measured telomere length in blood (leukocytes) and subcutaneous fat. RESULTS: Telomere length was highly variable among individuals but highly correlated among tissues (cells) within the individual. The mean telomere length in the keloids was longer than that in the adjacent normal skin and displayed a length gradient, with the mean length of telomeres shorter just below the epidermis and longer at the base of the keloids. No apparent telomerase activity was detected in the keloids. CONCLUSIONS: Our findings suggest a transient activation of telomerase, the reverse transcriptase that prevents telomere shortening, probably during the early phase of keloid formation. The activation of telomerase serves to maintain (or even elongate) telomere length in the keloid. However, telomerase activity is repressed in the fully developed keloid.

Multivariate predictors of failure after flap coverage of pressure ulcers.

BACKGROUND: Pressure ulcers are estimated to be present in more than one-third of patients with spinal cord injury. The rate of recurrence after flap surgery over last 50 years has ranged between 3 and 82 percent, with no trend toward improvement. This study seeks to identify and evaluate patient and operative characteristics associated with flap dehiscence and ulcer recurrence. METHODS: A retrospective chart review of all patients who underwent pressure ulcer flap coverage between 1993 and 2008 was performed. Thirty-one demographic and operative variables were collected. Multivariate logistic regression with generalized estimating equation was used to evaluate the effect of significant variables. The primary outcome was recurrence of pressure ulcer at the operative site. Secondary outcomes included flap line dehiscence and the need for operative revision. RESULTS: There were 88 recurrences of pressure ulcers after flap surgery (39 percent) of 227 operations performed on 135 patients. Thirty-six flaps (16 percent) had dehiscences necessitating return to the operating room. Hemoglobin A1c less than 6 percent and previous same-site flap failure were associated with both dehiscence and recurrence (odds ratios, 2.15 and 3.84; and odds ratios, 6.51 and 3.27). Younger age and albumin less than 3.5 were associated with early flap failure (odds ratios, 5.95 and 2.45). Ischial wound location correlated with late recurrence (odds ratio, 4.01). Patients with multiple risk factors had operative success rates that approached zero. CONCLUSIONS: Confirmation of adequate nutritional status and strict preoperative management of blood glucose may improve operative success rates. The authors propose that operative management should be approached with trepidation, if at all, in young patients with recurrent ischial ulcers.