Targeted Muscle Reinnervation: Factors Predisposing to Successful Pain Score Reduction.

BACKGROUND: Targeted muscle reinnervation (TMR) has demonstrated efficacy in reducing neuroma and chronic pain. In this article, we investigated postoperative outcomes in our patient cohort, with a focus on the role of nonmodifiable factors such as patient age and gender. METHODS: Patients who had extremity TMR from April 2018 to October 2022 were reviewed. Outcomes of interest included patient age, gender, cause and type of amputation, delayed versus immediate TMR, as well as postoperative improvement in pain as assessed by numerical rating score (NRS). RESULTS: A total of 40 patients underwent TMR on 47 limbs. Mean age was 46.2 ± 17.0 years. Delayed TMR (27, 57.4%) was most commonly performed, followed by immediate and delayed-immediate at 11 (23.4%) and 9 (19.1%), respectively. Amputation level was most commonly above-knee in 20 (42.6%) patients, followed by below-knee (12, 25.5%), transhumeral (8, 17.0%), transradial (6, 12.8%), and shoulder (1, 2.1%). The median time interval between amputation and TMR was 12 months. The median preoperative NRS assessing residual limb pain (RLP) for patients who underwent delayed TMR was 10. The median postoperative NRS assessing RLP for all patients was 0 (interquartile range25-75: 0-5) and significantly improved compared with preoperative NRS (P < 0.001). At the last follow-up for limbs that had delayed and delayed-immediate TMR (n = 36), 33 (91.7%) limbs had more than 50% resolution of RLP. There was a significant difference in median postoperative NRS by gender (4 in men and 0 in women) (P < 0.05). Postoperative median NRS also favored younger patients (0, <50 years compared with 4.5, >50 years) (P < 0.05). Multiple linear regression analysis showed that, of different variables analyzed, only male gender and older age were predictive of poorer postoperative outcomes. CONCLUSION: TMR showed high efficacy in our cohort, with improved short-term outcomes in women and younger patients.

Analgesic Efficacy of Nerve Blocks After Abdominoplasty: A Systematic Review.

BACKGROUND: A variety of regional nerve blocks have been utilized in abdominoplasty procedures, including transversus abdominis plane (TAP), intercostal, rectus sheath (RS), pararectus + ilioinguinal/iliohypogastric, quadratus lumborum, and paravertebral blocks. No consensus exists regarding the most effective nerve block modality in optimizing postprocedural comfort levels. OBJECTIVES: The purpose of this systematic review was to explore the efficacy of the various abdominal nerve blocks employed in abdominoplasty surgery and to draw attention to any modality that may be superior in regards to effectiveness and/or administration. METHODS: Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies that have employed regional nerve blocks in abdominoplasty procedures. Opioid consumption, pain scores, time to ambulation, time in the recovery room, and time to first analgesia request were extracted when available. RESULTS: A total of 191 articles were reviewed, of which 8 met inclusion criteria. The nerve blocks represented included TAP, RS, pararectus + ilioinguinal/iliohypogastric, intercostal, and quadratus lumborum. All modalities were effective in reducing opioid consumption except quadratus lumborum. CONCLUSIONS: TAP, RS, pararectus + ilioinguinal/iliohypogastric, and intercostal regional nerve blocks have been shown to optimize postoperative pain management in abdominoplasty procedures. The existing literature suggests that when studied against one another, TAP is more efficacious than RS and pararectus + ilioinguinal/iliohypogastric. When ultrasound guidance is unavailable, consideration should be given to TAP employing the direct visualization approach.

Topical ketoconazole for the treatment of androgenetic alopecia: A systematic review.

Androgenetic alopecia (AGA) is common and associated with significant psychosocial distress. Treatment options are needed for patients that do not adequately respond to first line treatments of finasteride or minoxidil. Topical ketoconazole has been proposed as a promising treatment. The goal of this systematic review was to evaluate the efficacy of topical ketoconazole in the treatment of AGA. A systematic literature search was conducted within the MEDLINE database using the key terms "ketoconazole" and "alopecia." Forty-seven papers were screened for inclusion, of which nine were assessed for eligibility. Seven articles were included in the qualitative synthesis, including two animal studies (total of 40 participants) and five human studies (total of 318 participants). Murine studies demonstrated a significant increase in mean ratio of hair regrowth to denuded area in the ketoconazole treatment groups compared to controls. Human studies reported increased hair shaft diameter following ketoconazole use. One study reported a significant increase in pilary index (percent anagen phase × diameter) following treatment. Studies also demonstrated clinical improvement of AGA based on photographic assessment and subjective evaluation. Topical ketoconazole is a promising adjunctive or alternative therapy in the treatment of AGA. Randomized controlled trials are needed.

Comparison of Saline Expanders and Air Expanders for Breast Reconstruction.

INTRODUCTION: Postmastectomy breast reconstruction with saline tissue expanders requires frequent saline injections. Air expanders contain an air canister and patient-operated remote to control expansion. The aim of this study was to evaluate the effectiveness of air expanders, inclusive of cost. METHODS: An international review board-approved retrospective review was performed of women who underwent breast tissue expansion between January 1, 2005 and February 5, 2019. Data collected included demographics, distance from clinic, mastectomy type, breast cancer treatment, expander type, expansion duration, postoperative visits, expansion visits, and postoperative complications. We compared true, unrealized, and overall costs and efficiency measured by time for expansion completion. True cost was calculated by adding expander, saline, and needle prices. Unrealized cost was calculated by multiplying number of visits for expansion by the expense of roundtrip driving. T tests and z scores determined clinical significance. RESULTS: Postoperative complication rates were not significantly different between groups. The air expansion mean true cost was US $1006.11 more than saline expansion (P < 0.001), whereas the mean unrealized cost was US $551.81 less (P = 0.008). The air expansion mean overall cost was US $461.43 more than saline expansion (P = 0.063). There was no significant difference in time to expander-to-implant exchange. CONCLUSIONS: This study demonstrates that saline and air expanders have no difference in complications or ability to complete expansion. However, there is significantly higher unrealized cost of saline expansion due to needle and saline costs and travel for more frequent doctor visits. However, saline expansion overall cost is less than air expansion, but statistically insignificant. Air expanders are effective in properly selected patients.