Vibrotactile Feedback for a Person with Transradial Amputation and Visual Loss: A Case Report.

Background and Objectives: After major upper-limb amputation, people face challenges due to losing tactile information and gripping function in their hands. While vision can confirm the success of an action, relying on it diverts attention from other sensations and tasks. This case report presents a 30-year-old man with traumatic, complete vision loss and transradial left forearm amputation. It emphasizes the importance of restoring tactile abilities when visual compensation is impossible. Materials and Methods: A prototype tactile feedback add-on system was developed, consisting of a sensor glove and upper arm cuff with related vibration actuators. Results: We found a 66% improvement in the Box and Blocks test and an overall functional score increase from 30% to 43% in the Southampton Hand Assessment Procedure with feedback. Qualitative improvements in bimanual activities, ergonomics, and reduced reliance on the unaffected hand were observed. Incorporating the tactile feedback system improved the precision of grasping and the utility of the myoelectric hand prosthesis, freeing the unaffected hand for other tasks. Conclusions: This case demonstrated improvements in prosthetic hand utility achieved by restoring peripheral sensitivity while excluding the possibility of visual compensation. Restoring tactile information from the hand and fingers could benefit individuals with impaired vision and somatosensation, improving acceptance, embodiment, social integration, and pain management.

Reduction of Phantom Limb Pain and Improved Proprioception through a TSR-Based Surgical Technique: A Case Series of Four Patients with Lower Limb Amputation.

Four patients underwent targeted sensory reinnervation (TSR), a surgical technique in which a defined skin area is first selectively denervated and then surgically reinnervated by another sensory nerve. In our case, either the area of the lateral femoral cutaneous nerve or the saphenous nerve was reinnervated by the sural nerve. Patients were then fitted with a special prosthetic device capable of transferring the sense of pressure from the sole of the prosthesis to the newly wired skin area. Pain reduction after TSR was highly significant in all patients. In three patients, permanent pain medication could even be discontinued, in one patient the pain medication has been significantly reduced. Two of the four patients were completely pain-free after the surgical intervention. Surgical rewiring of existing sensory nerves by TSR can provide the brain with new afferent signals seeming to originate from the missing limb. These signals help to reduce phantom limb pain and to restore a more normal body image. In combination with special prosthetic devices, the amputee can be provided with sensory feedback from the prosthesis, thus improving gait and balance.

Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases.

We report the outcomes of the European prospective study on prepectoral breast reconstruction using preshaped acellular dermal matrix for complete breast implant coverage. Seventy-nine patients were enrolled between April 2014 and August 2015 all over Europe using a single protocol for patient selection and surgical procedure, according to the Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guidelines for the use of acellular dermal matrix in breast surgery. The preshaped matrix completely wraps the breast implant, which is placed above the pectoralis major, without detaching the muscle. A total of 100 prepectoral breast reconstructions with complete implant coverage were performed. This series, with mean follow-up of 17.9 months, had two cases of implant loss (2.0%) including one necrosis of the nipple and one wound breakdown (1.0% respectively). No implant rotations were observed. Good cosmetic outcomes were obtained with natural movement of the breasts and softness to the touch; none of the patients reported experiencing pain or reduction in the movements of the pectoralis major muscle postoperatively. The use of preshaped acellular dermal matrix for a complete breast implant coverage in selected patients is safe and gives satisfactory results, both from the aesthetic view point and the low postoperative complication rates. Further studies reporting long-term outcomes are planned.

Extravasation of propofol is associated with tissue necrosis in small children.

Propofol is widely used for induction of anesthesia and many reports document extravasation and even intra-arterial injections without clinical sequelae. We report a case of tissue necrosis after subcutaneous injection of propofol in a 31-day-old infant.

Secondary end-to-end repair of extensive facial nerve defects: surgical technique and postoperative functional results.

BACKGROUND: Repair of the transected facial nerve is imperative for restoration of muscle function, including the ability to produce appropriate facial expressions. Injury might involve the main trunk and its several branches. Restoration of function presupposes meticulous repair of all injured nerve branches. METHODS: Here we report three cases of secondary tension-free end-to-end coaptation of a transected trunk and branches of the facial nerve by removal of the superficial part of the parotid gland. RESULTS: Facial tone and symmetry at rest and motion were achieved. In two patients, a slight residual synkinesis is observed under stress. CONCLUSIONS: Direct end-to-end coaptation of the facial nerve and its branches by the technique described should be considered before deciding on grafts or rerouting procedures to deal with gaps of up to 15 mm. This technique is not recommended in the presence of infection and nerve defects. Intensive postoperative physiotherapy is required for optimal results.

Aesthetic refinements in reconstructive microsurgery of the lower leg.

Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.

The zygomatic flap: a further possibility in reconstructing soft-tissue defects of the nose and upper lip.

Through the dissection and localization of the cutaneous zygomatic branch, as previously described by the authors, a vessel is available that plays an important role in reconstructive surgery. The performance of this anatomical study has enabled designing of the so-called zygomatic flap, which can be considered as a further possibility in the reconstruction of soft-tissue defects of the upper lip and nose. This new island axial pattern flap provides a reliable source of skin, with color match for facial resurfacing, and leaves a well-hidden donor site similar to that of the nasolabial flap. The flap must be carefully raised, and when properly designed, it can follow naturally existing contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal surgical deformity. In this article, the authors report the clinical application of the zygomatic flap and the outcome of 10 cases. In a follow-up period from 1998 to the end of 2002, there was no flap loss, and in all cases, the aesthetic results were excellent and highly acceptable to the patients. The authors' experience with this new island axial pattern flap has been good, and they recommend this technique.

Isolated compression of the pectoral nerve resulting in atrophy of the major pectoral muscle.

We report on two cases of isolated damage to a muscle branch of the lateral pectoral nerve. Diagnosis was established by the clinical presentation and electromyographic examination. In the few reported cases of such injuries, the cause was trauma to this region. However, in both of our patients, focal muscle atrophy gradually developed after initiation of training schedules to increase the cross-section of the major pectoral muscle; we therefore assume that compression injury to the nerve by repetitive muscle contractions may be of pathogenic relevance. Anatomical studies of this region showed that the nerve branches of the lateral pectoral nerve, having to pierce through a connective tissue septum that is thicker here by a few millimeters, may be subjected to additional risk of compression. Early recognition and treatment are vital to prevent associated morbidity of these rare but serious injuries.

A case of familial popliteal pterygium syndrome: early surgical intervention for successful treatment.

A 2-year-old boy presented at our hospital with severe familial popliteal pterygium syndrome with extensive skin webbing from thigh to heel and severely reduced range of motion of the knee and ankle joints. For accomplishment of knee extension, the patient underwent surgery with resection of the fibrous bands, freeing of the sciatic nerve, Z-lengthening of the Achilles tendon and multiple Z-plasties. One year after surgery, the patient can put his heel on the ground and has almost complete range of motion in the knee and ankle joints.

Does a superficial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique.

An exact knowledge of the subcutaneous layers in the different regions of the face and neck is important in several surgical disciplines. In the parotid region, a superficial musculoaponeurotic system (SMAS) has been described. The existence of a SMAS as a guiding structure for the surgeon in the other regions of the face and neck has been discussed but is controversial. Therefore, the authors investigated the development of the subcutaneous connective-tissue layers in the different facial regions and in the neck. They studied these regions in 22 human fetuses using the technique of plastination histology and in three newborn and three adult specimens using sheet plastination. In addition, they dissected the neck and face in 10 fresh adult cadavers to identify the SMAS as in the surgical situation. The results show that no SMAS could be detected in any facial regions other than the parotid region. In the parotid region, it is thick and attached to the parotid sheath. However, it becomes very thin, discontinuous, and undissectable in the cheek area. No SMAS can be found in the neck, in which the authors are the first to describe a fascia covering both sides of the platysma. This fascia has close topographical connections to the subcutaneous layers of the adjoining regions. On the basis of these findings, the surgical pathways have to be defined regionally in the face. A "platysma fascia" can be considered as a surgical landmark in the neck. Therefore, the authors conclude that it is not justified to generalize a SMAS as a surgical guiding structure.

Breast deformity in adolescence as a result of pneumothorax drainage during neonatal intensive care.

OBJECTIVE: During intensive care of newborns, a number of invasive techniques may be necessary for resuscitation. The margin of safety between effective treatment and iatrogenic damage is narrow. The objective of this study was to identify and discuss iatrogenic damage in females resulting from treatment of pneumothorax and to give neonatologists anatomically based advice for prevention. PATIENTS AND METHODS: We report 2 female patients (aged 13 and 16 years) born prematurely in whom breast deformity occurred caused by drainage of multiple pneumothoraces during intensive care. In an additional anatomic study, both hemithoraces of 5 newborn female cadavers (n = 10) were dissected to measure the extension of the breast tissue. RESULTS: The anatomic investigations in newborns demonstrate that breast tissue extends vertically from the second or third rib to the sixth rib and from close to the sternal edge medially, almost to the anterior axillary line laterally. CONCLUSION: Psychological distress and corrective surgery because of deformed breasts in adolescent girls who have undergone drainage of pneumothoraces as newborns can be avoided by placing the skin incision in the anterior axillary line, maintaining a distance of 4 to 5 cm inferior to the nipple, and by inserting the chest drain through the fifth or sixth intercostal space during neonatal treatment.

Composite skin grafts for basal cell carcinoma defects of the nose.

Basal cell carcinoma is the most frequent cutaneous cancer of the nose and is characterized by its local spreading and exceptionally rare tendency to metastasize. Since a significant advantage has been seen in surgery compared to other treatments, surgical excision ensuring the highest chance of cure is frequently employed. Excision defects of the nose may be covered with either local flap or a full-thickness skin graft. In resurfacing such defects following excision of basal cell carcinomas, we favor the technique of composite-skin grafting which involves the harvesting of composite-skin graft including the epidermis, dermis and superficial layers of subcutaneous tissue to obtain the required thickness in the recipient site. This technique was used for defects remaining after the excision of basal cell carcinomas in a series of 15 patients. The areas involved were lateral nasal region (5 cases), nasal tip (4 cases), dorsum (3 cases), alar lobule (2 cases), and soft triangle (1 case). The mean follow-up was 14.2 months. The color, texture and thickness of the composite-skin graft harvested from the preauricular site and the neck compare favorably with the skin of the nose region. Satisfactory results, both clinically and in patient appreciation, have been obtained in both the reconstruction site and the appearance of the donor site in all patients.

Ultrasonographic appearance of supinator syndrome.

OBJECTIVE: To describe ultrasonographic findings in 4 patients with supinator syndrome (i.e., deep branch of the radial nerve). METHODS: Four patients with weakness and pain in their forearm underwent ultrasonographic examination with subsequent electroneurographic testing and surgical nerve inspection. Normal measurements of the deep branch of the radial nerve in 10 healthy volunteers served as comparison for measurements in the patients. RESULTS: An enlarged deep branch of the radial nerve was found in all 4 patients at the affected side. Electroneurographic testing and surgical inspection confirmed the ultrasonographic findings. The mean transverse diameter was 4.2 mm (range, 3.8-4.5 mm), and the anteroposterior diameter was 3.3 mm (range, 2.5-3.8 mm). In volunteers, the mean transverse diameter was 2.13 mm (range, 1.7-2.6 mm), and the mean anteroposterior diameter was 1.3 mm (range, 1.0-1.5 mm). CONCLUSIONS: The deep branch of the radial nerve appears enlarged in patients with supinator syndrome.

Direct coaptation of extensive facial nerve defects after removal of the superficial part of the parotid gland: an anatomic study.

BACKGROUND: In the surgical repair of facial nerve paralysis, a tension-free end-to-end coaptation of the trunk or its branches with or without rerouting is functionally superior to grafting. Assuming that a lengthening of all branches of the parotid plexus can be attained by removal of the superficial part of the parotid gland and mobilization of the branches, we performed an anatomic study. METHODS: The parotid regions of 10 cadavers were dissected to investigate the length gained for the branches of the parotid plexus by this technique. Every branch at the upper and ventral border of the gland was marked by a surgical suture. After removing the superficial part of the parotid gland, the branches were cut at the suture, and the proximal stump was drawn toward the distal stump. The distance of the overlapping stumps was measured by means of an electronic gliding caliper. In addition, in five specimens only the trunk of the facial nerve was dissected by the same method, and the distance of the overlapping stumps was measured. RESULTS AND CONCLUSIONS: The results demonstrate that removing the superficial part of the parotid gland may be sufficient to enable direct coaptation without nerve grafting. Cut temporal or zygomatic branches with a gap of up to 15 mm and cut buccal or marginal mandibular branches with a gap of up to 23 mm can be bridged by mobilization of just the proximal stumps. This technique may also be used to bridge a 17-mm gap of the trunk of the facial nerve.