The Use of a Novel Chimeric Flexor Carpi Ulnaris and Ulnar Artery Flap for Elbow Coverage.

Elbow defects have a number of etiologies and present a difficult task for the reconstructive surgeon. A number of reconstructive options have been previously reported. We describe a case of a 54-year-old woman with a recurrent elbow defect secondary to prior trauma, surgical fixation, and infection. This was successfully managed with a novel chimeric flexor capri ulnaris and ulnar artery flap for coverage of the defect, which has not been previously described. This may serve as a useful guide for surgeons moving forward.

Worth Syndrome-Patient Report, Diagnostic Work-Up, and Surgical Management of a Rare Craniofacial Entity.

Worth syndrome is a rare genetic bone disorder that often presents with cortical thickening of the mandible and an increase in mandibular width. The authors report the preoperative considerations in a young female with Worth syndrome, operative planning, and successful mandibular reduction using cutting guides.

The Role of Augmented Reality in the Next Phase of Surgical Education.

Concomitant with such a shift toward competency-based curricula, there has been increasing adoption of surgical simulation coupled with virtual, mixed, and augmented reality. These technologies have become more commonplace across multiple surgical disciplines, in domains such as preoperative planning, surgical education, and intraoperative navigation. However, there is a relative paucity of literature pertaining to the application of this technology to plastic surgery education. This review outlines the advantages of mixed and augmented reality in the pursuit of an ideal simulation environment, their benefits for the education of plastic surgery trainees, and their role in standardized assessments. In addition, we offer practical solutions to commonly encountered problems with this technology. Augmented reality has tremendous untapped potential in the next phase of plastic surgery education, and we outline steps toward broader implementation to enhance the learning environment for our trainees and to improve patient outcomes.

Impact of Technology on Conjoined Twin Separation: Are We Further Ahead?

SUMMARY: The success of conjoined twin separation has increased since the 1950s, notwithstanding the numerous technical and physiologic challenges encountered in such procedures. Together with improvements in our understanding of conjoined twin physiology and the accumulation of surgical expertise, technological advances have largely paralleled the improvement in outcomes. In particular, advances in imaging modalities, adjuncts to abdominal wall closure such as mesh and tissue expansion, and three-dimensional modeling have been instrumental in advancing care for these patients. Considered together, these domains have allowed multidisciplinary teams to better delineate conjoined anatomy, facilitated improved surgical planning and decision-making, and assisted in overcoming the frequent challenges associated with soft-tissue closure. This review delineates the improvements in these modalities and their relationship to increasingly successful conjoined twin separation in recent years.

Conjoined Twin Separation: Review of 30-Year Case Experience and Lessons Learned.

BACKGROUND: Conjoined twinning is a rare medical phenomenon, and numerous challenges remain with respect to surgical separation and reconstruction. The purpose of this study is to present a detailed discussion of the authors' institutional experience with eight conjoined twin separations over the past three decades, focusing on challenges and lessons gleaned from these cases. METHODS: The records of all patients who underwent conjoined twin separation at The Hospital for Sick Children in Toronto, Ontario, Canada, from 1984 to 2018 were retrospectively reviewed. RESULTS: Eight sets of conjoined twins were analyzed. Half of the sets [ n = 4 (50 percent)] were female. There were four sets (50 percent) of ischiopagus twins, three sets (37.5 percent) of omphalopagus twins, and one set (12.5 percent) of craniopagus twins. The median age at separation was 6.75 months. The mean durations of intensive care unit and hospital stay were 14.1 ± 12.9 days and 4.9 ± 4.8 months, respectively. Mean length of follow-up was 6.7 ± 4.4 years. Three deaths occurred in our series, with an overall survival rate of 81 percent. Two sets of twins experienced expander-related complications such as infection and bowel perforation. Three twins required reoperation because of flap necrosis or dehiscence after separation. CONCLUSIONS: The authors' results highlight the unique nature of each operation and the great ingenuity required in managing the particular considerations of each case and also adhering to a systematic approach of evaluation and planning. A number of novel strategies were used at the authors' center and have now become commonplace. The lessons learned from such procedures may improve care for future generations of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

International Microsurgery Club: An Effective Online Collaboration System.

BACKGROUND: This study aimed to determine if International Microsurgery Club (IMC) is an effective online resource for microsurgeons worldwide, in providing an avenue for timely group discussions and advice regarding complicated cases, and an avenue for collaboration and information sharing. METHODS: All posts on the IMC Facebook group from member 1 to 8,000 were analyzed according to inclusion criteria and categorized into three categories-case discussion, question, and information sharing. Posts were retrospectively analyzed for number of responses, time of responses, number of "likes," number of treatment options, time of day, and demographics of authors and responders. RESULTS: A retrospective analysis of 531 cases showed an average response rate of 75.7% within 1 hour and as membership grew. The response rate stabilized averaging between 72.5 and 78% across all times of the day. An average of 11.8 microsurgeons was involved per case discussion, and 5.7 treatment options were provided per case. CONCLUSION: IMC is shown to be an effective resource to allow microsurgeons to access timely advice from other microsurgeons without time and distance limitation, and to have interactive group discussions on complicated cases.

Can a Partially Injured Donor Nerve Restore Elbow Flexion in an Acute Brachial Plexus Injury in Rats?

BACKGROUND: Loss of elbow flexion commonly occurs following acute brachial plexus injury. The double fascicular transfer is often used in acute C5-C6 and C5-C7 root injuries, but is rarely applied in cases involving concomitant C8 or T1 root injury. The authors designed a rat model using varying severities of lower trunk injury to determine whether partial injury to the lower trunk affects nerve transfers for elbow flexion. METHODS: There were four different rat groups in which 0, 25, 75, or 100 percent of the donor lower trunk remained intact. One-fourth of the cross-sectional area of the ulnar nerve was then transferred to the musculocutaneous nerve immediately. The authors assessed outcomes using a grooming test, muscle mass, retrograde labeling of sensory/motor neurons that regenerated axons, and immunohistochemical stain of regenerated axons. RESULTS: Five months after nerve transfer, rats that underwent partial injury of the lower trunk fared significantly worse than the rats in whom the donor lower trunk remained 100 percent intact, but significantly better than the rats with 0 percent intact lower trunk. Rats with 25 or 75 percent of the lower trunk intact recovered equivalent function, at both the donor and recipient sites. CONCLUSIONS: Although relatively weak compared with the 100 percent intact donor lower trunk group, the partially injured donor nerve was still functional; even though the nerve sustained a partial injury, the residual axons reinnervated the target muscles. The power of the muscles following either 25 percent or 75 percent injuries was equal after the recovery. Resorting to this approach may be useful in cases in which no alternatives are available.

Vascularized Brachial Plexus Allotransplantation-An Experimental Study in Brown Norway and Lewis Rats.

BACKGROUND: Brachial plexus injuries are devastating. Current reconstructive treatments achieve limited partial functionality. Vascularized brachial plexus allotransplantation could offer the best nerve graft fulfilling the like-with-like principle. In this experimental study, we assessed the feasibility of rat brachial plexus allotransplantation and analyzed its functional outcomes. METHODS: A free vascularized brachial plexus with a chimeric compound skin paddle flap based on the subclavian vessels was transplanted from a Brown Norway rat to a Lewis rat. This study has 2 parts. Protocol I aimed to develop the vascularized brachial plexus allotransplantation (VBP-allo) model. Four groups are compared: no reconstruction, VBP-allo with and without cyclosporine A immunosuppression, VBP autotransplantation (VBP-auto). Protocol II compared the recovery of the biceps muscle and forearm flexors when using all 5, 2 (C5 + C6) or 1 (isolated C6) spinal nerve as the donor nerves. The assessment was performed on week 16 and included muscle weight, functionality (grooming tests, muscle strength), electrophysiology and histomorphology of the targeted muscles. RESULTS: Protocol I showed, the VBP-allo with cyclosporine A immunosuppression was electrophysiologically and functionally comparable to VBP-auto and significantly superior to negative controls and absent immunosuppression. In protocol II, all groups had a comparable functional recovery in the biceps muscle. Only with 5 donor nerves did the forearm show good results compared with only 1 or 2 donor nerves. CONCLUSIONS: This study demonstrated a useful vascularized complete brachial plexus allotransplantation rodent model with successful forelimb function restoration under immunosuppression. Only the allotransplantation including all 5 roots as donor nerves achieved a forearm recovery.

Sensory and functional morbidity following sural nerve harvest in paediatric patients.

BACKGROUND: The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients' ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients. METHODS: A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) - Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper. RESULTS: Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function. CONCLUSIONS: Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit.

Case-Cohort Studies: Design and Applicability to Hand Surgery.

Observational studies are common research strategies in hand surgery. The case-cohort design offers an efficient and resource-friendly method for risk assessment and outcomes analysis. Case-cohorts remain underrepresented in upper extremity research despite several practical and economic advantages over case-control studies. This report outlines the purpose, utility, and structure of the case-cohort design and offers a sample research question to demonstrate its value to risk estimation for adverse surgical outcomes. The application of well-designed case-cohort studies is advocated in an effort to improve the quality and quantity of observational research evidence in hand and upper extremity surgery.

Use of Social Media and an Online Survey to Discuss Complex Reconstructive Surgery: A Case of Upper Lip Reconstruction with 402 Responses from International Microsurgeons.

BACKGROUND: The best reconstructive strategy for upper lip defects is still in debate. The purpose of this study was to analyze the decisions made by international microsurgeons, who were participated through online questionnaire, distributed by email and social media network. MATERIALS AND METHODS: A case of a two-thirds upper lip oncologic defect was presented via an online questionnaire and 402 microsurgeons replied their treatment options. The data were then analyzed according to the geographic area, microsurgical fellowship, seniority, and subspecialty. All the data were analyzed using SPSS 22. RESULTS: A total of 27.7% of microsurgeons chose a free flap, while 72.3% chose a local/pedicle flap as their preferred method for reconstruction. The most common choice of free and local/pedicle flaps was radial forearm (73.6%) and Abbé (36.2%), respectively. The microsurgeons in Europe preferred local/pedicle flaps than free flap when compared with Middle/South America, Asia-Pacific, Africa and South Asia/Middle East (11.6% versus 50%, 43.4%, 29.3% and 27.3%, respectively, multivariant p < 0.05). The microsurgeons with microsurgical fellowships preferred to use free flaps (32.9% versus 17.5%, multivariant p = 0.021). There was no difference for the seniority and specialty of the microsurgeons. CONCLUSIONS: The online questionnaire is valuable and feasible for obtaining experts' opinions. This study provides a current global overview of surgical preferences for this common complicated clinical scenario.

Outcomes following coronary artery bypass grafting with microsurgery in paediatric patients.

OBJECTIVES: Paediatric coronary artery bypass grafting is indicated in cases of clinically significant and symptomatic coronary stenosis, with frequent complications occurring in the perioperative period. To reduce complications and improve outcomes of these procedures, surgical microscopes have been used at our centre with the anastomosis performed by a microvascular surgeon. The purpose of this article is to report our institutional experience in all patients who have undergone paediatric coronary artery bypass grafting procedures with and without microvascular techniques. METHODS: Twenty-four patients who underwent coronary artery bypass grafting from January 2000 to May 2017 were retrospectively reviewed. RESULTS: Eighteen patients underwent bypass without microvascular involvement and 6 patients required the use of microsurgical techniques. Median age at the time of operation was 9.79 and 2.02 years for the 2 groups, respectively. The median weight at the time of operation was 41.2 and 10.75 kg for the 2 groups, respectively. Procedures were performed emergently in 4 patients. Three major anastomotic complications occurred requiring reoperation, although none occurred in the microvascular group. The median follow-up was 3.40 years and 5.25 years for the 2 groups, respectively. Three patients were symptomatic at last follow-up and 2 deaths occurred, all in the non-microvascular group. All grafts were patent in both groups. There were no statistically significant differences between preoperative and postoperative ejection fraction between the groups. CONCLUSIONS: Our results highlight the potential positive impact of collaboration between cardiac and microvascular surgeons during paediatric coronary artery bypass grafting procedures and the subsequent reduction in complications that may be expected.

Reverse Distal Transverse Palmar Arch in Distal Digital Replantation.

BACKGROUND: Refinements in microsurgery have made distal finger replantation an established technique with high success rates and good functional and aesthetic outcomes. However, it still represents a technically demanding procedure due to the small vessel caliber and frequent lack of vessel length, requiring the use of interpositional venous grafts in some instances. We describe a new technique for anastomosis in fingertip replantation, whereby the need for venous grafts is eliminated. METHODS: Applying the reverse distal transverse palmar arch technique, 11 cases of distal digital replantation were performed between January 2011 and July 2016. The described procedure was used for arterial anastomosis in 10 cases and arteriovenous shunting for venous drainage in 1 case. A retrospective case review was conducted. The technical description and clinical outcome evaluations are presented. RESULTS: Ten of the 11 replanted digits survived, corresponding to an overall success rate of 91%. One replant failed due to venous insufficiency. Blood transfusions were not required for any of the patients. Follow-up (range, 1.5-5 months) revealed near-normal range of motion and good aesthetic results. All of the replanted digits developed protective sensation. The average length of hospital admission was 5 days. All patients were satisfied with the results and were able to return to their previous work. CONCLUSIONS: The use of the reverse distal transverse palmar arch is a novel and reliable technique in distal digital replantation when an increase in vessel length is required, allowing for a tension-free arterial repair without the need for vein grafts.