Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes.

BACKGROUND: Low efficacy, significant side effects, and refractory patients often limit the medical treatment of migraine headache. However, new surgical options have emerged. Dr. Bahman Guyuron and others report response rates between 68 and 95 percent after surgical deactivation of migraine trigger sites in select patients. In an effort to replicate and expand migraine trigger-site deactivation surgery as a treatment option, the authors' group and others have developed nonendoscopic algorithms. The exclusion of endoscopic techniques may be useful for surgeons with little experience or limited access to the endoscope and in patients with challenging anatomy. METHODS: Forty-three consecutive trigger deactivation procedures in 35 patients were performed. Preoperative and 12-month postoperative migraine questionnaires and patient charts were reviewed. Response to surgery in terms of migraine symptom relief and adverse events were evaluated. RESULTS: The overall positive response rate was 90.7 percent. Total elimination of migraine headaches was reported in 51.3 percent of those with a positive response, greater than 80 percent resolution of symptoms was reported in 20.5 percent, and 28.2 percent had resolution between 50 and 80 percent. No significant effect was reported following 9.3 percent of procedures. There were no major adverse events. CONCLUSIONS: Nonendoscopic trigger deactivation is a safe and effective treatment in select migraine headache patients. Although surgical techniques and understanding of the mechanisms of relief are evolving, results continue to be promising. This series confirms that excellent results can be attained without the endoscope. The authors continue to study these patients prospectively to improve patient selection and refine the protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Beyond biologics: absorbable mesh as a low-cost, low-complication sling for implant-based breast reconstruction.

BACKGROUND: There is an intense push to decrease overall healthcare costs in the United States. Although the use of acellular dermal matrix in implant-based reconstruction has grown significantly over the past decade, potential drawbacks remain a source of debate. Matrices are costly and not universally available across institutions, whereas Vicryl mesh is widely available, relatively inexpensive, and resistant to bacteria biofilm formation. With the intent of maximizing the reconstructive and economic advantages of direct-to-implant breast reconstruction, the authors report the first experience in the literature using an absorbable mesh as an inferolateral sling. METHODS: A retrospective review was performed of the first 50 consecutive patients (76 reconstructions) who underwent implant-based breast reconstruction with Vicryl mesh from August of 2011 until June of 2012. RESULTS: Fifty patients underwent 76 direct-to-implant reconstructions with Vicryl mesh between August of 2011 and June of 2012 (mean follow-up, 1.2 years). Five breasts (6.6 percent) had complications, with only one complication resulting in implant loss (1.3 percent). Implant positioning and contour were excellent, with only two patients [three breasts (3.9 percent)] undergoing revision procedures, for size enlargement. Using costs available at the authors' institution, use of Vicryl mesh instead of acellular dermal matrix resulted in a direct material cost savings of $172,112 in 10 months. CONCLUSIONS: Results to date have been encouraging, with a low complication rate (6.6 percent) and excellent aesthetic results. The technique has resulted in $172,112 in direct material cost savings over 10 months. Continued follow-up is planned to evaluate long-term results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

SPLIT rectus abdominis myocutaneous double free flap for extremity reconstruction.

A Mathes and Nahai type III muscle, such as the rectus abdominis muscle, can be utilized to cover two separate wounds simultaneously utilizing its dual blood supply thereby minimizing donor site morbidity and operative time. We report a case for treatment of bilateral Gustillo type IIIB lower extremity injuries treated with a single rectus abdominis muscle split into two free flaps, with one based on the deep inferior epigastric vessels and one on the superior epigastric vessels to cover the contralateral wound. In our patient, both lower extremity wounds were covered with muscle flaps from the same donor site in a single operation, salvaging both limbs with progression to unassisted ambulatory status. We show in this case report that the utilization of the vascular anatomy of the rectus muscle allows for division of the flap into two flaps, permitting preservation of the contralateral abdominal wall integrity and coverage of two wounds with a single muscle.

Congenital entropion.

Entropion is a malposition of the eyelid causing an abnormal inversion of the eyelid margin. This results in symptomatic contact of the eyelashes with the surface of the globe, resulting in corneal irritation. Symptoms primarily arise from irritation of the ocular surface. Corneal abrasions and scarring can occur. Although common in many canine breeds, it is rare in the pediatric congenital form and rarely reported in the literature. Success in treatment depends on diagnosing the appropriate cause and selecting a surgical procedure that adequately addresses the underlying abnormality. The authors describe a pediatric patient with congenital entropion and review the nature of the problem and its treatment options.