The Scratch-Collapse Test: Are Electrodiagnostic Changes Measurable?

INTRODUCTION: Carpal tunnel syndrome is commonly managed by hand and upper extremity surgeons. Though electrodiagnostics are considered the gold standard diagnosis, the scratch collapse test (SCT) was introduced to address uncertainty, despite remains controversial. To address this, we sought to identify if the SCT can correlate with EDS studies if the SCT can identify actual changes in measures of nerves. METHODS: We reviewed patients who underwent electrodiagnostic studies (EDX) and SCT for carpal tunnel syndrome (CTS). Demographic data as well as sensorimotor amplitudes, latencies, and velocities on nerve conduction and electromyography were collected. Analogous values based on SCT findings were analyzed for statistical significance. RESULTS: Three hundred fifty patients with CTS were included. Sensory and motor velocities and amplitudes were significantly lower in patients with a positive SCT. Motor values were independent of age, though younger patients had larger measured changes. Obese patients did not show any motor EDX changes with the scratch collapse test, though thinner patients did. All changes were seen in nerve conduction only. CONCLUSIONS: Carpal tunnel can be a difficult problem to diagnose as one study does not singularly determine the condition. The SCT was introduced to facilitate easier diagnosis. We demonstrate that the SCT correlates with changes on nerve conduction studies, especially in relation to decreased amplitudes and velocities, suggesting that it does identify changes in nerve with compression, specifically axonal, and myelin damage. These findings support the use of the SCT maneuver to evaluate and diagnose in appropriate patients.

The PUG Flap: Conjoined Profunda Artery Perforator and Upper Gracilis Flap for Breast Reconstruction.

Abdominal-based free flaps are the mainstay of autologous breast reconstruction; however, the region may not be ideal for patients with inadequate soft tissue or history of abdominal surgery. This case describes the use of a novel conjoined flap based on the profunda artery perforator and upper gracilis pedicles, named the perforator and upper gracilis (PUG) flap. This flap design aims to maximize medial thigh flap volume while ensuring robust tissue perforation. Here, we present our experience with the PUG flap in a breast cancer patient undergoing autologous reconstruction. The patient was a 41-year-old woman seeking nipple-sparing mastectomy and immediate autologous reconstruction with the PUG flap due to limited abdominal tissue availability. The gracilis and profunda artery perforator flaps were elevated using one boomerang-style skin paddle. Once harvested, the flaps were inset with antegrade and retrograde flow off the internal mammary arteries and both respective internal mammary veins. The donor site was closed in a V-Y pattern resulting in a thigh lift-type lift and concealed scar. In conclusion, the boomerang-style PUG flap maximizes medial thigh free tissue transfer volume, offers internal blood flow redundancy, and maintains good cosmesis of the donor site.

Can You Go the Distance: Collagenase Clostridium histolyticum Manipulation at 1 Month after Injection.

Collagenase Clostridium histolyticum is a popular treatment in Dupuytren contracture. Current guidelines are for manipulation 24 hours to 7 days after injection. We present a case of successful manipulation 28 days after injection.

Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review.

PURPOSE: The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects. METHODS: A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap. RESULTS: Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%). CONCLUSIONS: Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

Evaluation of the Risk of Hypertrophic Scarring and Keloid Following Eyelid Procedures: A Systematic Review.

BACKGROUND: Eyelid surgeries are common operations performed for both cosmetic and functional purposes. Because the periorbital region is highly visible, it is important to avoid poor scar formation in this cosmetically sensitive region. No study to date has investigated the possible existence of keloid formation following eyelid procedures. OBJECTIVES: This study systematically reviewed the literature to identify cases of hypertrophic scar and keloid formation following cosmetic or functional (nonburn) eyelid procedures to aid surgeons when counseling patients. METHODS: A PubMed/MEDLINE search was conducted on May 17, 2022, using appropriate search terms: "blepharoplasty," "tarsorrhaphy," "canthotomy," "ptosis repair," "epicanthoplasty," "keloid," "hypertrophic scar," and related lay terms. All eligible articles in English with no lower date limit were included for analysis. Descriptive statistics, exclusion criteria, and summarized results are reported. RESULTS: The PubMed search yielded 107 abstracts/articles. Full-text review resulted in 34 articles included for analysis. Twenty manuscripts reported no occurrences of hypertrophic scars. Only 13 manuscripts reported patients with hypertrophic scarring, which equated to 36 patients out of 3650. One individual was identified in a series of 77 patients who developed a keloid after a tarsorrhaphy. No articles reported a keloid as an outcome of strictly cosmetic procedures. CONCLUSIONS: This study concludes that there are no reported instances of keloid formation following cosmetic (nonburn) eyelid procedures in the existing literature. Hypertrophic scar formation is minimally reported. The absence of keloid scar formation on the eyelid is critical knowledge for surgeons when educating patients about maladaptive scarring risks following eyelid procedures.

The Role of Resection of the Outer Table of the Cranium in Locally Invasive Primary Squamous Cell Carcinoma of the Scalp.

INTRODUCTION: Nonmelanoma skin cancer is the most common malignancy of the scalp. Of these, squamous cell carcinoma (SCC) is the most troublesome. It poses a challenge to the surgeons caring for these patients as the anatomy of the scalp makes excision and reconstruction difficult. Although more superficial lesions are amenable to Mohs micrographic surgery, more invasive lesions require a different approach. This manuscript is a retrospective review of outer table resection for SCC of the scalp invading to the depth of the pericranium. We include a discussion of full thickness craniectomy for invasive SCC, regardless of depth of invasion, for completeness. METHODS: IRB approval was obtained from St. Joseph's Hospital and Medical Center in Phoenix, Arizona. One hundred four potential cases identified based on ICD codes. Ultimately, 23 cases met study criteria and were included in this analysis. Seventeen cases of outer table resection and 6 cases of full craniectomy were discussed. Additionally, the authors' approach for resection and reconstruction is articulated. RESULTS: Seventeen patients underwent outer table resection at an average age of 79.3 years. All had invasion of the pericranium with a mean surface area of 42.6 cm 2 . Eight patients had prior radiation treatment for SCC of the scalp and 12 patients had at least 1 prior surgery to attempt excision of their lesions. Two patients had local recurrence for a local control rate of 88.2% (15/17). One patient with metastasis prior to presentation, died 6 months after his initial surgery for disease-free survival rate of 94.1% (16/17) at a mean of 15.4months. Thirteen patients were able to achieve immediate reconstruction with local flaps with or without additional skin grafting (76.5%). DISCUSSION: The data in this study supports that in instances of locally invasive primary SCC of the scalp that extends to the pericranium, excision down to the calvarium with complete circumferential and deep peripheral margin assessment, followed by resection of the outer table, is an excellent option. The low rate of local recurrence and high disease-free survival in this study support that this method allows for optimal oncologic outcome while mitigating the significant morbidity associated with the alternative option of a full thickness craniectomy.

The Effects of Website and Social Media Presence of Integrated Plastic Surgery Residency Programs on Prospective Applicants: An Analysis During the Coronavirus Disease 2019 Pandemic.

PURPOSE: Integrated plastic surgery residency programs have increased their social media presence to educate and recruit prospective residents. This study aims to understand the impact of integrated plastic surgery residency program social media on the 2020 to 2021 applicants' evaluation of prospective programs, particularly during the coronavirus disease 2019 pandemic. MATERIALS AND METHODS: An optional 20-item online survey was sent to integrated plastic surgery residency applicants applying to the authors' program. RESULTS: Surveys were sent to 300 integrated plastic surgery residency applicants with an average of 168 responses (56% response rate). Social media resources included official residency program website (87.1%), Instagram (70.2%), and Doximity (46.8%). The most frequently used resource by applicants was the official residency program website (43.9%); Instagram was the second most frequently used (40.2%) followed by Doximity (8.3%). Most respondents agreed that social media was an effective means to inform applicants (66.1%), and it positively impacted their perception of the program (64.8%). The cited benefits were helping the program exhibit its culture and comradery among residents, faculty, and staff (78.4%). Among applicants, 73.6% noted that it had a significant impact on their perceptions of programs. Most respondents truncated their planned plastic surgery subinternships, completing 1 instead of 3 planned subinternships because of coronavirus disease 2019 limitations. CONCLUSIONS: During the 2020 to 2021 plastic surgery application cycle, applicants used social media accounts of plastic surgery residency programs to inform and educate themselves about prospective programs. This study suggests that investing resources into a social media residency accounts is a meaningful pursuit for integrated plastic surgery programs and is an important aspect in today's recruitment.

The Effect of Anticoagulation on the Treatment of Dupuytren Contracture with Collagenase.

BACKGROUND: There have been no formal studies of the use of collagenase clostridium histolyticum (Xiaflex; Endo Pharmaceuticals, Malvern, Pa.) in the anticoagulated patient. Previous study on its use excluded patients receiving anticoagulation therapy. This study reviewed the effects of anticoagulation use in patients undergoing collagenase clostridium histolyticum injection and cord rupture to determine safety and efficacy. METHODS: The authors retrospectively reviewed patients receiving collagenase clostridium histolyticum injections for Dupuytren contracture between 2010 and 2017. Outcomes included type of anticoagulation, skin tear, tendon rupture, lymphadenopathy, sensory abnormality, hematoma, and bleeding. RESULTS: A total of 388 injections were performed in 197 patients. The average clinical follow-up was 311 days. Fifty-two percent of patients (n = 201) were anticoagulated. The vast majority were taking aspirin (acetylsalicylic acid) (n = 182), followed by warfarin (n = 27), clopidogrel (n = 9), apixaban (n = 8), rivaroxaban (n = 4), and dabigatran (n = 2). There were 42 skin tears, 21 in the anticoagulated group. One tendon rupture occurred in the anticoagulated group (acetylsalicylic acid) and none occurred in the nonanticoagulated group (p = 0.34). No patients experienced sensory abnormalities, a hematoma requiring intervention, or uncontrollable bleeding. CONCLUSIONS: Anticoagulation is commonly encountered by hand surgeons treating Dupuytren contracture. There is no significant difference in complications in the anticoagulated patient versus the nonanticoagulated patient. It is safe to perform collagenase clostridium histolyticum injections for Dupuytren contracture in the anticoagulated patient, regardless of the type of anticoagulation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Addition of an Oblique Interfragmentary Screw to T-plate Fixation Decreases Nonunion Rate in Trapeziometacarpal Arthrodesis.

Background: T-plate fixation is a popular method for trapeziometacarpal arthrodesis in patients with osteoarthritis. Previous studies report an 8% to 18% rate of symptomatic nonunion and a 26% rate of radiographic nonunion. In this study, we present our surgical technique of trapeziometacarpal arthrodesis using the addition of an oblique interfragmentary screw to T-plate fixation on the rate of symptomatic and radiographic nonunion. Methods: A retrospective review of all trapeziometacarpal arthrodeses for osteoarthritis was completed by a single surgeon between 2010 and 2018. Preoperative demographics, pain, and Eaton classification were included. The technique was identical in all surgical cases, using a T-plate and oblique interfragmentary screw across the arthrodesis site from the metacarpal to the trapezium. Postoperative nonunion rate and time to clinical healing (absence of pain) and radiographic union were reviewed. Results: A total of 22 trapeziometacarpal arthrodeses were performed on 17 patients using the above technique. The average age was 53 years, 71% were women, and 53% involved the dominant hand. Mean preoperative Eaton classification was 2.74 (±0.73). Mean time to clinical healing was 34 days (±12 days), and mean time to radiographic union was 55 days (±23 days). Mean follow-up was 9 months, and no patients were found to have symptomatic or radiographic nonunion. Hardware removal was required bilaterally in 1 patient after complete healing. Conclusions: The addition of an oblique interfragmentary screw to T-plate fixation is a novel technique in trapeziometacarpal arthrodesis, resulting in no symptomatic or radiographic nonunion.

Composite Anterolateral Thigh and Fascia Lata Free Flap for Abdominal and Groin Reconstruction in a Pediatric Patient.

Large abdominal wall and groin defects present complex reconstructive challenges. These defects typically require free flap reconstruction to bring in healthy vascularized tissue and recreate the complex full-thickness defect. A 6-year-old previously healthy girl presented to our trauma center after sustaining a close-range shotgun injury resulting in a full-thickness defect to the inferior hemi-abdomen and groin. A composite anterolateral thigh flap with fascia lata free flap was performed to reconstruct the myofascial, skin, and subcutaneous tissue of the abdomen and groin. We present the first composite anterolateral thigh flap with fascia lata for full-thickness abdominal wall and groin reconstruction in a pediatric patient.

Three-dimensional Printing in Plastic Surgery: Current Applications, Future Directions, and Ethical Implications.

BACKGROUND: Three-dimensional printing (3DP) is a rapidly advancing tool that has revolutionized plastic surgery. With ongoing research and development of new technology, surgeons can use 3DP for surgical planning, medical education, biological implants, and more. This literature review aims to summarize the currently published literature on 3DP's impact on plastic surgery. METHODS: A literature review was performed using Pubmed and MEDLINE from 2016 to 2020 by 2 independent authors. Keywords used for literature search included 3-dimensional (3D), three-dimensional printing (3DP), printing, plastic, surgery, applications, prostheses, implants, medical education, bioprinting, and preoperative planning. All studies from the database queries were eligible for inclusion. Studies not in English, not pertaining to plastic surgery and 3DP, or focused on animal data were excluded. RESULTS: In total, 373 articles were identified. Sixteen articles satisfied all inclusion and exclusion criteria, and were further analyzed by the authors. Most studies were either retrospective cohort studies, case reports, or case series and with 1 study being prospective in design. CONCLUSIONS: 3DP has consistently shown to be useful in the field of plastic surgery with improvements on multiple aspects, including the delivery of safe, effective methods of treating patients while improving patient satisfaction. Although the current technology may limit the ability of true bioprinting, research has shown safe and effective ways to incorporate biological material into the 3D printed scaffolds or implants. With an overwhelmingly positive outlook on 3DP and potential for more applications with updated technology, 3DP shall remain as an effective tool for the field of plastic surgery.

Pyoderma gangrenosum confined to the irradiated chest wall of the reconstructed breast.

Pyoderma gangrenosum (PG) is a diagnosis of exclusion worsened by surgical debridement. This report presents two atypical manifestations of PG in the reconstructed breast, whereby the disease is only confined to the irradiated chest wall tissue bed, sparing the abdominal donor sites and the contralateral reconstructed breast.

Representation of Women on Plastic Surgery Journal Editorial Boards in the United States.

BACKGROUND: During the past decade, a growing number of women have pursued medical careers, including in plastic surgery. However, female physicians have tended to be underrepresented in a variety of leadership roles in their respective specialties. OBJECTIVES: The authors sought to evaluate the representation of female plastic surgeons on the editorial boards of high-impact plastic surgery journals. METHODS: The gender of editorial board members on 3 high-impact plastic surgery journals was evaluated from 2009 and 2018. The number of women on each editorial board was then compared with the number of board-certified female plastic surgeons (BCFPS) and board-certified female academic plastic surgeons (BCFAPS), a subgroup of BCFPS. RESULTS: There were 555 unique editorial board members from Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, and Annals of Plastic Surgery from 2009 to 2018. During that period, 72 editors (13.0%) were women. At the beginning of the study, there were significantly fewer female editors than expected based on proportionate representation of BCFPS and BCFAPS to all board-certified plastic surgeons (P = 0.007 and 0.007, respectively). During the study, there was a 177% increase in women holding editorial board positions. At study end, women were adequately represented on all 3 editorial boards compared with their population data (BCFPS and BCFAPS). CONCLUSIONS: During the 10 years of this study (2009-2018), editorial boards have overcome the underrepresentation of women on, and female plastic surgeons are currently adequately represented on the top 3 high-impact journal editorial boards.

A Navajo Patient with Morbihan's Disease: Insight into Oculoplastic Treatment of a Rare Disease.

Morbihan's disease is classically defined as primarily a Caucasian disease of chronic, recurrent erythema and nonpitting edema of the middle and upper thirds of the face. The disease is often difficult to diagnose and challenging to treat. Medical management is the primary treatment modality; however, if there is progression of the disease that causes visual impairment, surgical debulking is often required. We present the first reported case of Morbihan's disease in a Navajo patient in conjunction with a review of the literature on surgical management of this challenging disease.