Chimeric versus Multiple Flaps for Composite Oral Cavity Defects: A Systematic Review and Meta-Analysis.

OBJECTIVES: Complex head and neck defects involving composite defects can be reconstructed using chimeric flaps or multiple flaps with separate anastomoses. Limited comparisons exist between chimeric and multiple flap reconstructions. We compare outcomes between chimeric and multiple flap reconstructions in oral cavity reconstruction. DATA SOURCES: PubMed (NLM), Embase (Elsevier), Web of Science (Clarivate Analytics), and Cochrane CENTRAL (Wiley). METHODS: A systematic review was conducted, including English articles reporting outcomes of oral cavity reconstruction with either chimeric flaps or multiple flaps. Data extraction included patient characteristics, flap type, and outcomes such as flap survival, partial flap loss, operating room time, hospital length of stay, and postoperative complications. RESULTS: Forty-seven articles comprising 1435 patients were included. Notably, 552 patients underwent multiple flaps, while 883 received chimeric flaps. Meta-analysis revealed no statistically significant difference in flap survival between chimeric and multiple flap patients (98% vs. 99%, p = 0.198). Multiple flap patients had higher rates of operating room take-backs for anastomotic issues and longer hospital stays compared with chimeric flap patients. There were no significant differences in partial flap failure, resumption of diet and speech, need for subsequent flaps, fistula formation, or general complications. CONCLUSION: This large-scale meta-analysis demonstrates equivalent flap survival between chimeric and multiple flaps in the reconstruction of composite oral cavity defects. Both approaches appear to be safe and acceptable, with comparable outcomes in terms of diet and speech resumption, rates of fistulization, and general postoperative complications. Multiple flap patients had higher rates of operating room take-backs and longer hospital stays. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Forearm Lipoma Causing PIN Compression: Literature Review and Meta-Analysis of Predictors for Motor Recovery.

BACKGROUND: Lipomas are a rare cause of posterior interosseous nerve (PIN) compression. A systematic review of predictors for motor recovery has not been performed. This study sought to evaluate whether patient or lipoma characteristics are associated with motor recovery and could be used to determine when immediate tendon transfers at the time of excision should be performed. METHODS: Articles describing patients with forearm lipomas resulting in PIN compression with motor weakness were included. Patient age, gender, symptom duration, laterality and largest dimension of lipoma, surgical intervention, and motor recovery were identified. Article quality was assessed via the Methodological Index for Non-Randomized Studies criteria. RESULTS: Thirty articles reporting on 34 patients were identified. Average age was 58.2 years. Average largest lipoma dimension was 5.7 cm. All patients underwent lipoma removal, and 2 had concomitant tendon transfers. In all, 73.5% of patients had complete motor recovery at an average of 9.7 months. Patient age and largest dimension of lipoma, and duration of symptoms were not significant predictors of motor recovery. Symptom duration was a significant predictor of motor recovery in binary regression, particularly if < 18 months. CONCLUSIONS: The majority of patients with PIN weakness secondary to lipoma are likely to have complete motor recovery after excision alone. Concomitant tendon transfers should be considered for patients symptomatic for greater than 18 months. Further, adequately powered, studies are required to stratify risk factors and evaluate other modalities to identify the minority of patients who would benefit from immediate tendon transfer.

ACTA2 Mutation: Microsurgeon Beware!

Patients with the alpha actin 2 genetic mutation suffer early onset aneurismal and vascular-occlusive conditions due to dysfunctional smooth muscle contractility. Outcomes of free flap reconstruction in this patient population are unknown. Here we report the case of a 21-year-old woman with alpha actin 2 mutation who required decompressive hemicraniectomy following an acute stroke. The entire Cushing flap underwent necrosis, requiring debridement and exposing dura. This condition was treated with a free latissimus myocutaneous flap. The patient's post-operative course was complicated by venous thrombosis, requiring intra-flap tPA and revision of the venous anastomosis with a saphenous vein graft. Ultimately the distal 75% of the flap was lost, leaving the dura exposed. The patient's course was further complicated by multiple wound healing complications: large areas of necrosis of the latissimus and saphenous vein donor sites, the neck vessel recipient site, and the right hand after IV infiltration. She ultimately healed with a regenerative tissue matrix strategy. Reconstructive options with no or minimal donor site morbidity should be considered in patients with the alpha actin 2 mutation. We encourage further reporting of outcomes in these patients.

Pyogenic Flexor Tenosynovitis Caused by Shewanella putrefaciens.

Flexor tenosynovitis is a surgical emergency due to the risk of tendon necrosis which can lead to subsequent amputation. We report a case of flexor tenosynovitis with Shewanella putrefaciens as the implicated organism, though the patient's mechanism of penetrating trauma did not involve a marine exposure. Shewanella are Gram negative bacilli associated with marine environments and have rarely been implicated in human disease. This patient presented with all four of Kanavel's signs and required open surgical irrigation and debridement; he was found to have purulence but no flexor tendon necrosis. This case emphasizes the importance of considering marine organisms as putative for flexor tenosynovitis, even if marine exposure does not occur at the time of the penetrating trauma. It also emphasizes the need to obtain a thorough patient history, especially in cases of infection, to assess for all possible environmental exposures.

Updated Dynamics of Rhinoplasty: A Review of the Literature and Comprehensive List of the Findings.

BACKGROUND: The cardinal reason accounting for the complexity of rhinoplasty is that each maneuver during this operation has both intended and unintended effects. The purpose of this report is to review the literature and update the dynamics of rhinoplasty. METHODS: PubMed searches were conducted for "rhinoplasty dynamics" as well for keywords associated with each specific rhinoplasty maneuver. Titles were evaluated for relevance, and duplicates were consolidated with years of publication 1991 to 2019. Article types include case series (retrospective and prospective), cohort studies, and review articles. RESULTS: Beginning with the radix, its reduction apparently elongates the nose and widens the intercanthal space, while radix augmentation creates the opposite illusions. In a similar manner, dorsal hump reduction widens both the nose and intercanthal space. Nasal tip dynamics focus on the aftermath of changes to tip projection, width, and rotational position. Resection of the upper lateral cartilages can cephalically rotate the tip and reduce tip width. Manipulation of the footplates of the medial crura primarily influences the columella but can also affect tip projection. Placement of a columellar strut firmly establishes tip position. Placement of alar rim grafts advances the ala caudally, widens the nostrils, and elongates the short nostril. Alar base reduction can create the illusion of increased tip projection. Augmentation and reduction in the anterior nasal spine influence tip projection, upper lip length, and the nasolabial angle. CONCLUSIONS: As rhinoplasty techniques continue to evolve, surgeons undertaking this operation must continue to reassess the dynamics of various maneuvers. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Incidence of Psychiatric Medication Use and Its Effect on Intraoperative Bleeding in Facial Cosmetic Patients.

PURPOSE: Psychiatric medications, particularly the selective serotonin reuptake inhibitors, have been associated with increased surgical bleeding. This study aims to compare intraoperative surgical bleeding between cosmetic surgery patients who are and are not taking psychiatric medications. METHODS: The charts of 392 consecutive patients who underwent cosmetic facial surgery at the senior author's practice were reviewed. Independent variables included self-reported psychiatric history, psychiatric diagnoses, and psychiatric medications as documented in the preoperative history and physical examination. The primary endpoint was administration of desmopressin (DDAVP), our proxy for increased surgical bleeding. Significant predictors of these endpoints were determined via Chi-squared testing. RESULTS: One hundred and seventeen patients had a psychiatric diagnosis (30%), and 129 patients were taking some class of psychiatric medication (33%). Seventy-two patients received DDAVP (18%). A psychiatric diagnosis did not predict DDAVP administration (14.3% for patients with a psychiatric diagnosis vs. 20.88% for those without, p = 0.14). The use of a psychiatric medication was not associated with DDAVP administration (14.7 vs. 21%, p = 0.14). Male gender significantly predicted DDAVP administration (27.8 vs. 16.9% for females, p = 0.04). CONCLUSION: The use of psychiatric medications does not predict increased intraoperative surgical bleeding. This is useful given the prevalence of psychiatric medication use among this patient population and obviates the need for discontinuation of these medications, which otherwise could be consequential. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Emergence of Secondary Trigger Sites after Primary Migraine Surgery.

BACKGROUND: Surgical decompression of a migraine headache may unmask headaches originating from secondary sites. A retrospective chart review investigated the incidence and characteristics of secondary trigger sites to identify clinical patterns that could aid in predicting and perhaps reducing postoperative migraines. METHODS: One hundred eighty-five charts for migraine patients who underwent surgery at the senior author's (B.G.) practice were reviewed. Sites from which migraine headaches initiated or occurred independently were considered primary. The sites that were not active at the time of preoperative evaluation but became active after surgery were considered secondary. Bivariate analysis was performed to characterize postoperative migraines. RESULTS: Of 185 patients, 33 (17.8 percent) developed secondary migraine headache trigger sites. Of patients with primary site I (frontal) symptoms, 20.83 percent had site III (septonasal) symptoms unmasked after surgery (versus 7 percent for patients with other primary sites; p = 0.04). Of the patients with site II (temporal) migraines, 17.14 percent had secondary frontal symptoms (versus 5.68 percent; p = 0.04). Primary site II symptoms predicted postoperative site IV (occipital) symptoms (11.43 versus 1.1 percent; p = 0.008), and primary occipital symptoms predicted postoperative temporal symptoms (11.1 versus 2.33 percent; p = 0.04). CONCLUSIONS: The authors observed that 17.8 percent of patients develop postoperative migraine headache triggers that are not reported during the initial assessment. Knowledge of secondary migraine emergence patterns, and the presence of some preoperative symptoms, can aid in predicting the migraines that will arise from a new site postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ontogenetic changes in the olfactory antennules of the shore crab, Hemigrapsus oregonensis, maintain sniffing function during growth.

Malacostracan crustaceans capture odours using arrays of chemosensory hairs (aesthetascs) on antennules. Lobsters and stomatopods have sparse aesthetascs on long antennules that flick with a rapid downstroke when water flows between the aesthetascs and a slow return stroke when water is trapped within the array (sniffing). Changes in velocity only cause big differences in flow through an array in a critical range of hair size, spacing and speed. Crabs have short antennules bearing dense arrays of flexible aesthetascs that splay apart during downstroke and clump together during return. Can crabs sniff, and when during ontogeny are they big enough to sniff? Antennules of Hemigrapsus oregonensis representing an ontogenetic series from small juveniles to adults were used to design dynamically scaled physical models. Particle image velocimetry quantified fluid flow through each array and showed that even very small crabs capture a new water sample in their arrays during the downstroke and retain that sample during return stroke. Comparison with isometrically scaled antennules suggests that reduction in aesthetasc flexural stiffness during ontogeny, in addition to increase in aesthetasc number and decrease in relative size, maintain sniffing as crabs grow. Sniffing performance of intermediate-sized juveniles was worse than for smaller and larger crabs.

In-depth review of symptoms, triggers, and treatment of temporal migraine headaches (Site II).

BACKGROUND: This study was designed to report the details of the technique and assess the efficacy of surgical deactivation of temporal-triggered migraine headaches. It also examined the effect of surgical deactivation of temporal-triggered migraine headaches on migraine triggers and associated symptoms besides the pain. METHODS: The authors analyzed the charts of 246 patients receiving surgery for temporal-triggered migraine headaches by a single surgeon (B.G.) over a 10-year period, who were followed for at least 1 year. Median regression adjusted for age, sex, and follow-up time was used to determine postoperative reduction in temporal-specific migraine headache index, which is the product of frequency, severity, and duration. The association between individual symptom or trigger resolution and index value reduction was studied by logistic regression. Details of the surgical treatment are discussed. RESULTS: Eighty-five percent of patients reported a successful surgery (≥50 percent improvement of headache index) at least 12 months after surgery (mean follow-up, 3 years). Fifty-five percent reported complete elimination of temporal migraine headache. Symptoms resolving with successful site II surgery included nausea, photophobia, phonophobia, difficulty concentrating, vomiting, blurry vision, and eyelid ptosis (p < 0.05). Triggers resolving included letdown after stress, air travel, missed meals, bright lights, loud noises, fatigue, weather change, and certain smells (p < 0.05). CONCLUSIONS: Surgical deactivation of temporal-triggered migraine headaches is effective regardless of age, sex, or follow-up time. Successful site II surgery is associated with changes in specific symptoms and triggers. This information can assist in trigger avoidance and contribute to constellations used for temporal-triggered migraine headaches trigger-site identification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.