Preoperative Prophylactic Antibiotics in Mandibular Fractures and Surgical Site Infection.

BACKGROUND: Compared with other facial fractures, mandibular fractures have the highest rate of postsurgical site infection. There is strong evidence to suggest that postoperative antibiotics do not reduce rates of surgical site infections (SSIs) regardless of duration. However, there are conflicting data in the literature regarding the role of prophylactic preoperative antibiotics in reducing rates of SSIs. This study reviews the rate of infections in patients who underwent mandibular fracture repair who received a course of preoperative prophylactic antibiotics compared with those who received no or 1 dose of perioperative antibiotics. METHODS: Adult patients who underwent mandibular fracture repair at Prisma Health Richland between 2014 and 2019 were included in the study. A retrospective cohort review was conducted to determine the rate of SSI, comparing 2 groups of patients who underwent mandibular fracture repair. Patients who received more than 1 dose of scheduled antibiotics before surgery were compared with those who did not receive any antibiotic treatment before surgery or received only a single dose of antibiotics within 1 hour of incision time (perioperative antibiotics). The primary outcome was the rate of SSI between the 2 groups of patients. RESULTS: There were 183 patients who received more than 1 dose of scheduled antibiotics before surgery and 35 patients who received a single dose of perioperative antibiotics or did not receive any antibiotics. The rate of SSI was not significantly different in the preoperative prophylactic antibiotics group (29.3%) compared with the patients who received a single perioperative dose or no antibiotics (25.0%). CONCLUSION: Extended regimens of preoperative prophylactic antibiotics beyond a single dose at time of surgery do not reduce SSIs after surgical repair in mandibular fractures.

The Utility of the 5-Factor Modified Frailty Index to Predict Postoperative Risk in Microsurgical Reconstruction.

BACKGROUND: Microsurgical reconstruction is an integral part of plastic surgery. The 5-factor modified frailty index (5-mFI) is an effective tool to predict postoperative complications across multiple subspecialties. We aimed to determine if frailty scores using the 5-mFI can predict postoperative complications specifically in microvascular reconstruction. STUDY DESIGN: Frailty scores were retrospectively assessed in microsurgical reconstruction patients (2012-2016) using the American College of Surgeons National Quality Improvement Program base. The 5 variables that comprise the 5-mFI are history of chronic obstructive pulmonary disease, history of congestive heart failure, functional status, hypertension requiring medication and diabetes. The data were analyzed using the Goodman test, χ2 test, and a logistic regression model. The congruence was also compared between the 5-mFI and the American Society of Anesthesiology (ASA) classification in predicting complications. RESULTS: Of 5894 patients, the highest 5-mFI value was "3." Analyses show an increase in postoperative complications requiring ICU care. Further models indicate an association between readmission with hypertension and chronic obstructive pulmonary disease (P < 0.05). There was an increased risk of a failure to wean from ventilator with a history of chronic obstructive pulmonary disease and diabetes and an increased risk of readmission with a history of hypertension and chronic obstructive pulmonary disease. The 5-mFI and ASA were incongruent in predicting postoperative complications. CONCLUSIONS: The 5-mFI predicts postoperative complications in the microsurgical reconstruction population. Although the 5-mFI and ASA predict different complications, their use provides insight into the potential adjustable risks before surgery.

Palmar Creases and Their Implication on Carpal Tunnel Surgery.

BACKGROUND: A thorough knowledge of normal and variant anatomy of the wrist and hand is fundamental to avoiding complications during carpal tunnel release. The purpose of this study was to document variations of the surface anatomy of the hand to identify a safe zone in which the initial carpal tunnel incision could be placed. The safe zone was identified as the distance between the radial side of hook of hamate and the ulnar edge of the origin of the motor branch of the median nerve (MBMN). METHODS: Kaplan's cardinal line and other superficial markers were used to estimate the size of the safe zone, in accordance to prior published anatomical studies. The presence of a longitudinal palmar crease (thenar, median, or ulnar creases) within the safe zone was recorded. RESULTS: Of the 150 participants (75 male, 75 female) examined, the average safe zone widths were 10.85 (right) and 10.28 (left) mm. In all the hands examined, 86.33% of the safe zones (259 of 300) contained a longitudinal palmar crease. In the White population (n = 50), the average safe zone widths were 11.49 (right) and 10.01 (left) mm; in the African American population (n = 50), the average safe zone widths were 12.27 (right) and 12.01 (left) mm; and in the Asian population (n = 50), the average safe zone widths were 8.79 (right) and 8.82 (left) mm. On overage, males had a larger safe zone width than females by 4.55 mm. CONCLUSIONS: Although there seems to be variability between race and sex with regard to safe zone width, finding 86.33% of longitudinal palmar creases within the safe zone suggests that, for most patients, the initial carpal tunnel surgery incision may be hidden within the palmar crease while minimizing the risk of motor branch of the median nerve injury. Overall, the safe zone width is on average up to 10.5 mm measured from the hook of the hamate along Kaplan's cardinal line.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS: Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS: The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION: The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

Traumatic Abdominal Wall Hernia Repair with Dermal Autograft within a Morel-Lavallée Lesion.

Morel-Lavallée lesions and traumatic abdominal wall hernias seldom present together and have no standardized guidelines for treatment. We present a unique case of a traumatic abdominal wall hernia present within a patient's abdominal Morel-Lavallée lesion, which was reduced and repaired with a dermal autograft. This is a novel approach to repairing a rare and unusual injury. The literature suggests that tension-free repairs with mesh should be used on delayed repairs of traumatic abdominal wall hernias. However, some advocate for primary repairs due to an up to 50% increased risk of wound infection in these injuries, even without the use of mesh. Although infection rates with the use of biologic mesh (acellular dermal matrices) in a contaminated field are lower than that of synthetic mesh, infections still occur and tend to be higher in repairs without mesh. The lack of foreign material and innate immunogenicity of the patient's own dermis may theoretically decrease the risk of infection compared with other commercially-available and biologically-derived products. The patient is a 47-year-old woman who was in a motor vehicle accident with prolonged extrication time. She was hospitalized for approximately 6 months due to extensive injuries, but had no further complications from her Morel-Lavallée lesion or repair of her traumatic abdominal wall hernia with her own dermis.

Modified Carpal Tunnel Release: A New Approach to Minimizing Pillar Pain.

INTRODUCTION: Pillar pain is a frequent postoperative complication of carpal tunnel release (CTR). The precise definition of pillar pain is lacking, but most authors describe it as diffuse aching pain and tenderness in the thenar and hypothenar area. The etiology of pillar pain is unclear. However, the most prevalent theory is the neurogenic theory, which attributes the pain to the damage of small nerve branches of palmar cutaneous branches of median nerve after surgical incision, with resulting entrapment of the nerves in the scar tissue at the incision site. We postulated that a main source of pillar pain is sensory neuromas along the incision site.In this article, we describe a simple modification of the standard CTR technique with intent to decrease neuroma formation and thus minimizing pillar pain. MATERIALS AND METHODS: This is a retrospective study comparing the incidence and duration of pillar pain between patients who underwent standard CTR (SCTR, n = 53) versus the minimizing pillar pain CTR technique (n = 55). Based on duration of pillar pain, the groups were placed into 3 subgroups (<3, 3-6, and >6 months). Presence and duration of pillar pain in each group were recorded along with return to work (RTW), complications, and patient satisfaction. RESULTS: The SCTR group had a total of 17 patients with pillar pain (32.1%), 5 of which resolved within 3 months, 7 within 3 to 6 months, and 5 in more than 6 months. The group that underwent the minimizing pillar pain technique had a total of 4 patients with pillar pain (7.2%). Three resolved within 3 months, 1 resolved within 3 to 6 months, and there were no patients with pillar pain lasting more than 6 months. Average RTW time for minimization of pillar pain CTR (MPPCTR) was 34.9 days. Average RTW time for SCTR was 54.8 days. Satisfaction was higher among patients who underwent surgery with MPPCTR. CONCLUSIONS: Based on these results, we concluded that MPPCTR compared with SCTR had equal complication rate, however, significantly lower incidence and duration of pillar pain, higher rate of satisfaction, and earlier RTW.

Sternotomy Wound Closure: Equivalent Results with Less Surgery.

BACKGROUND: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap-based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. METHODS: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. RESULTS: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. CONCLUSION: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix.

BACKGROUND: The inverted T (Wise pattern) mastectomy for patients with macromastia or significant breast ptosis has evolved along with generalized techniques for breast reconstruction. We present a review of Wise pattern breast reconstruction along with our technique for direct to implant reconstruction using dermal matrix. METHODS: The literature was reviewed and an analysis of techniques and complications was performed. We present our series of patients incorporating dermal matrix and relatively large implants in direct to implant reconstruction. RESULTS: Of 18 breasts reconstructed only 2 failed. One caused by flap necrosis secondary to smoking and one as a result of preoperative radiation. CONCLUSION: Wise pattern breast reconstruction using relatively large implants and dermal matrix in direct to implant reconstruction is a safe technique in selected patients with macromastia.

Innervated Pedicled Gracilis Flap for Dynamic Abdominal Wall Reconstruction.

Abdominal wall reconstruction for full-thickness defects is a challenging procedure that usually requires the use of flaps. The gracilis flap is known to be used in hernia repair in which the abdominal muscles are still intact, but there are no reports in literature describing the use of an innervated gracilis for dynamic abdominal wall reconstruction after tissue loss due to severe trauma. We present a surgical technique in which the gracilis is harvested preserving the neurovascular pedicle, then tunneled underneath the adductor longus to cover the lower abdominal defect and provide it with basal muscle tone without tension on the pedicle. This results in restored integrity of the musculofascial abdominal wall and dynamic muscle function and support. The gracilis flap has been proven to be useful and versatile in reconstructive surgery with great potential in abdominal wall reconstruction having minimal donor-site morbidity and hernia recurrence risk.

Anomalous Radial Artery as an Incidental Finding During a Routine Carpal Tunnel Release.

BACKGROUND: Compression of the median nerve at the wrist, or carpal tunnel syndrome, is the most commonly recognized nerve entrapment syndrome. Carpal tunnel syndrome is usually caused by compression of the median nerve due to synovial swelling, tumor, or anomalous anatomical structure within the carpal tunnel. METHODS: During a routine carpal tunnel decompression, a large vessel was identified within the carpal tunnel. RESULTS: The large vessel was the radial artery. It ran along the radial aspect of the carpal tunnel just adjacent to the median nerve. CONCLUSIONS: The unusual presence of the radial artery within the carpal tunnel could be a contributing factor to the development of carpal tunnel syndrome. In this case, after surgical carpal tunnel release, all symptoms of carpal tunnel syndrome resolved.

A Novel Approach for the Treatment of Spider Veins.

BACKGROUND: Spider veins on the lower limbs are very common and have been reported to be present in 41% of women over 50. Sclerotherapy as a traditional treatment for spider veins has a low cost, though it may have adverse sequelae. Lasers have shown fewer but still substantial complications as well. Its lower efficacy relative to sclerotherapy has limited laser application for the treatment of spider veins. OBJECTIVES: To present a new alternative in management of spider veins which involves a low voltage current delivered via an insulated micro needle with beveled tip. METHODS: Thirty female patients were treated with the "Given Needle." The technique utilizes a micro needle with an insulated shaft with an exposed beveled tip, which is inserted into a hand piece connected to a mono-polar electrical generator. The needle is introduced through the skin into or on the spider vein. The current is then applied with obliteration of the vein. RESULTS: Twenty patients (66%) had more than a 70% resolution. The most common complication was skin erythema, which developed in 15 patients, followed by bruising in 13 patients. Both of these complications resolved in 2-3 weeks. CONCLUSIONS: A novel approach for the treatment of spider veins has been described. The development of an insulated micro needle with an exposed beveled tip utilizing low current has minimized adjacent tissue damage and improved efficacy. The low cost, low level of complications, and comparable results offer a valuable alternative to sclerotherapy and laser treatment.

An evaluation of the information gained from the use of intraoperative nerve recording in the management of suspected brachial plexus root avulsion.

BACKGROUND: The authors examine the information gained from the use of intraoperative nerve recording in the management of suspected brachial plexus root avulsion. METHODS: A retrospective chart review examined 25 patients who had undergone intraoperative nerve recording for a brachial plexus injury. Thirty-seven preganglionic root avulsions were demonstrated by somatosensory evoked potentials, C4 to T1, during intraoperative nerve recording. To measure the information gain derived from intraoperative nerve recording, the authors compared the number of roots diagnosed as preganglionic root avulsions preoperatively to those diagnosed by intraoperative nerve recording. From this, the authors can demonstrate the positive and negative predictive values of their preoperative multimodality assessment for brachial plexus root avulsion and compare this to the result of intraoperative nerve recording to derive the gain of information. In addition, the authors examined the validity of the intraoperative nerve recording somatosensory evoked potentials when this produced a diagnosis of an intact root in this cohort by performing a clinical outcome analysis for those roots used for reconstruction. RESULTS: Twenty-five patients underwent intraoperative nerve recording for unilateral brachial plexus injury; 15 patients were diagnosed with 55 preganglionic root avulsions from C4 to T1 preoperatively by multimodality assessment. Fourteen of 55 roots thought to be avulsed preoperatively were found to be intact with intraoperative nerve recording, representing a gain of information of 25 percent derived from intraoperative nerve recording for roots thought to be avulsed preoperatively. CONCLUSION: Intraoperative nerve recording adds useful information during exploratory brachial plexus surgery.

The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications.

BACKGROUND: The purpose of this study was to determine the location, size, and vascular territory of the radial artery cutaneous perforators. METHODS: Twenty-six human cadaveric forearms were dissected. All cutaneous radial artery perforators were analyzed for total number, orientation, location, and external diameter. A cluster analysis was performed to determine the overall distribution of perforators. The cutaneous territory of a distally based pedicled perforator flap was determined using methylene blue injection and three-dimensional computed tomographic angiography in five flaps. RESULTS: Six hundred thirty-nine perforators (399 perforators smaller than 0.5 mm compared with 240 perforators 0.5 mm or larger) were dissected in 26 forearms. Of the 639 radial artery perforators dissected, 328 (51 percent) were radially distributed and 311 (49 percent) were ulnarly distributed. There are two main clusters of clinically relevant perforators at a relative distance of 17.6 percent and 61.7 percent along the radial styloid-to-lateral epicondyle interval. In all cases, two or more perforators were found within 2 cm proximal to the styloid. Dye injection of the most dominant distally based perforators revealed a cutaneous territory ranging from 104 cm2 to 333 cm2. The case presented is of a patient with a dorsal hand defect, which was resurfaced with a pedicled perforator flap based on a distal perforator proximal to the radial styloid. CONCLUSIONS: There are two main clusters of clinically significant radial artery perforators. Increased knowledge of size, location, and cutaneous territory of the radial artery perforators can lead to expanded use of the radial artery forearmflap based on cutaneous perforators alone, without sacrificing the radial artery.

Simultaneous surgical release of ipsilateral pronator teres and carpal tunnel syndromes.

BACKGROUND: Because of overlapping symptoms, carpal tunnel syndrome is sometimes diagnosed and a more proximal site of compression may be missed. Incomplete relief following carpal tunnel surgery may be caused by the failure to identify the second site of compression. METHODS: A retrospective review was performed on 61 patients who were diagnosed as having both carpal tunnel syndrome and pronator teres syndrome of the ipsilateral median nerve. Besides precise medical history and physical evaluation, nerve conduction velocity studies and electromyography were performed. All patients but two had ipsilateral endoscopic carpal tunnel release and pronator teres release. Results after surgery were clinically assessed and evaluated as follows: complete relief, partial relief, or no relief. RESULTS: Postoperative evaluation resulted in 39 of 61 patients (64 percent) experiencing complete relief. Thirteen patients (21 percent) had partial relief. Eight of these patients were secondarily diagnosed with more proximal compression. Five of them had thoracic outlet compression syndrome, and three of them had cervical radiculopathy. For five patients, no specific reason was found for experiencing only partial relief. Nine patients (15 percent) had no significant relief. Among those patients, four were diagnosed with thoracic outlet compression syndrome and two with cervical radiculopathy; for three patients, the authors found no specific reason for failure. CONCLUSION: The main benefit of using this protocol in this selected group of patients is to shorten total morbidity time and to avoid exposure of the patient to two operations instead of one.