Reconstructive defects of the human face pose unique challenges to even the most experienced surgeon given their myriad of presentations and the individuality of each patient’s anatomy, clinical presentation, and perspective or preferences. A robust armamentarium of reconstructive options must be cultivated for each facial subunit so that experience and artistry can be best utilized to rebuild the patient’s structure and function. This review will outline a subset of local rotation and transposition flaps that are most useful for facial reconstruction, organized by facial subunit.
Skin grafts may be used for coverage of facial defects in situations in which alternative methods of reconstruction, such as local flaps, are not an option. They may also be beneficial for patients who wish to avoid or who are not good candidates for more complex reconstruction. Full-thickness skin grafts often have a better color and texture match to adjacent skin when compared to split-thickness grafts; however, split-thickness grafts have lower metabolic demand and increased survival rate. Composite grafts may be very useful in the repair of defects with unique contour and support requirements, such as the nasal ala and eyelid. With all grafts, thoughtful planning and sound surgical technique are critical in achieving the best possible functional and aesthetic result.
This report describes the procedure of a case in which the skin paddle of the free fibula flap derived its supply solely from a soleal musculocutaneous perforator originating from the posterior tibial system. In contrast, the osteo-muscular component was supplied by the peroneal vascular system. We harvested the skin paddle with its vascular supply from the posterior tibial artery separately, and the osteo-muscular fibula was harvested with its supply from peroneal vessels. In this way, we avoided violation of the second donor site for the skin paddle. In addition, we used the distal end of peroneal vessels to salvage our skin paddle instead of sacrificing another set of neck vessels for anastomosis. This technique may also be utilised in cases where the neck vessels may not be available due to previous surgeries, radiation therapy, or decision by the surgery team to not sacrifice two sets of neck vessels for anastomosis.
Photoaging and carcinogenesis are facilitated by oxidative stress, inflammation, angiogenesis, and extracellular matrix (ECM) remodeling. Oxidative effects include DNA damage, membrane oxidation, lipid peroxidation, and alterations in the expression of p53 and antioxidant enzymes. The inflammatory and angiogenesis mediators include interleukin-1, tumor necrosis factor-α, interleukin-8, transforming growth factor-β, and vascular endothelial growth factor. ECM remodeling includes alterations in the expression and organization of collagen, elastin, matrix metalloproteinases, and elastase. 1α, 25-dihydroxy-vitamin D3 has antioxidant, anti-inflammatory, and ECM regulatory properties, and can counteract the processes that facilitate photoaging and carcinogenesis. This review provides an overview of the beneficial effects of vitamin D supplementation at a molecular level, followed by a brief discussion regarding its use as a supplement.
Female urethral stricture (FUS) is a rare condition. It was not studied robustly for many years, but interest has grown recently in the reconstructive urology community, leading to an increase in publications. In this review, we gather the latest data regarding FUS and its different therapeutic options. Studies are summarized, split by technique. We also review the recently published European Guidelines. In addition, we share our preferred surgical technique and our views on future options. Diagnosing FUS can often be challenging and requires a high index of clinical suspicion. Its vague clinical symptoms and empiric initial treatments combine to make FUS an underdiagnosed condition. The lack of consensus on how to define FUS also compounds the problem. Appropriate diagnosis requires thorough investigation, and ancillary studies such as video urodynamics, cystoscopy, and voiding cystourethrogram may be useful. Treatment options range from conservative management to definitive procedures, although studies have shown that conservative measures such as urethral dilation have a low success rate overall. Within definitive management, augmented urethroplasty - using either flaps or grafts, has proven to be the gold standard. Both have shown excellent results over time; however, there is insufficient data available to recommend one over the other. Contemporary data has an overall poor level of evidence. Although challenging due to the rarity of the problem, a proper randomized controlled clinical trial comparing the principal surgical options and their outcomes would be beneficial and would allow for more informed decision making when considering options for women with urethral stricture.
Scalp reconstruction requires keen insight into underlying anatomy and surgical armamentarium. The reconstructive surgeon must consider a plethora of complexities to devise a safe and cosmetically maximized outcome. The purpose of this article is to review scalp reconstruction techniques and the current literature in the framework of the reconstructive ladder, with special emphasis on local flap consideration, design, and execution.
Aim: The aim of this study was to evaluate hard and soft tissue changes following guided bone regeneration (GBR), with occlusive titanium barriers (OTB), in the rehabilitation of partially edentulous atrophic jaws. Vertical bone gain (VBG), horizontal bone width (HBW), and flap thickness (FT) changes, observed between the first and the second surgical stages, were evaluated.
Methods: The study included 35 patients (9 men and 26 women; mean age 60 ± 10.53 years) in need of vertical bone augmentation for implant placement. Seventy implants were placed, 44 with a one-stage approach (Group A) and 26 with a two-stage approach (Group B). VBG, HBW, and FT were measured and statistically compared.
Results: VBG for implants placed in Group B was significantly higher than those placed in Group A (P = 0.006). The increased HBW in Group B was highly significant compared to that exhibited in Group A (P = 0.000). A highly significant difference was found in FT before and after the GBR in the two groups considered together, for both the upper and lower jaws (P = 0.000 for both).
Conclusions: OTBs are reliable devices in GBR, yielding predictable results in terms of bone augmentation. In almost all cases (94.3%), a spontaneous increase of the FT, at the second surgical phase, was observed. This could be due to the titanium surface features which increases spontaneously the thickness of soft tissues over the OTB.
Lip and perioral augmentation procedures have become increasingly popular over the last two decades due to cultural trends, emphasizing youth and beauty. An understanding of lip anatomy and aesthetics has traditionally formed the basis for successful results. However, as new technology becomes available, patient standards have increased, requiring an intricate understanding of filler properties and the advantages of different technical approaches. This chapter touches on pertinent anatomy and aesthetics of perioral evaluation. It also provides an overview of the properties of the fillers currently available in the United States marketplace for perioral rejuvenation. The technique and materials currently favored by the senior author are described in greater detail. Finally, the chapter will overview potential complications and recommended management.
Deformities in the body contouring population are rarely isolated to one area, and procedures can be combined to achieve more substantial results. While there is no formula for optimal surgical sequencing and timing, there are certain principles which - when applied appropriately - can yield results that are reliable, aesthetically pleasing, and aligned with the patient’s desires and preferences. In this article, we outline our latest thinking in circumferential body contouring and how to integrate the lower body lift with procedures of the abdomen, upper body, breasts, back, and arms to achieve the complete 360° look.
Despite significant advances in abdominal wall reconstruction, parastomal hernias remain a complex problem, with a high risk of recurrence following repair. While a number of surgical hernia repair techniques have been proposed, there is no consensus on optimal management. Several clinical variables must be considered when developing a comprehensive repair plan that minimizes the likelihood of hernia recurrence and surgical site occurrences. In this review, we describe the incidence of parastomal hernias and discuss pertinent risk factors, medical history findings, physical examination findings, supplementary diagnostic modalities, parastomal hernia classification systems, surgical indications, and repair techniques. Special consideration is given to the discussion of mesh reinforcement, including available biomaterials, anatomic plane selection, and the extent of mesh reinforcement. Although open repairs are the primary focus of this article, minimally invasive laparoscopic and robotic approaches are also briefly described. It is our hope that the provided surgical outcome data will help guide surgical management and optimize outcomes for affected patients.
Auricular defects resulting from excision of cutaneous malignancies pose a challenge to the reconstructive surgeon due to the complex anatomy, convexities, and concavities of the ear. A surgeon must be familiar with analyzing defects of the ear and understand the variety of reconstructive options available with the goals of restoring function, re-establishing anatomic units, and achieving aesthetic balance. This review summarizes current methods for reconstruction of partial auricular defects resulting from neoplasm. A brief overview of ear anatomy and aesthetic relationships is also provided. Techniques for the reconstruction are classified by anatomic region: upper-third, middle-third, and lower-third defects.
Several studies demonstrated the favorable effects of platelet rich plasma (PRP) on the skin and promoted its wide use in clinical practice. The growth factors stored in platelet alfa-granules allow for the tissue regeneration and the main fields of application of PRP in current clinical practice are the cartilage and musculoskeletal defects, osteoarthritis and other bone disorders, chronic and difficult to heal wounds, and aesthetic procedures. The relevant number of different PRP preparation protocols may explain the inconsistency of the different clinical outcomes reported in the literature. Despite the technological advances in PRP preparation, the objective assessment of the clinical efficacy of PRP from the literature reports still is difficult due to the low homogeneity of the samples in terms of both inclusion criteria and size. Therefore, it might be useful to establish standardized and reproducible experimental models to confirm and objectively measure the effectiveness of the available clinical results. Many experimental investigations have been carried out to objectively assess the effectiveness of PRP and platelet gel on several tissues. As far as the skin is concerned, the studies carried out to date are limited to fibroblasts in in-vitro culture models or to collagen, vascular supply, epithelium, and hair follicle in in-vivo models. The skin, however, is a very complex organ, where different cell lines coexist and feature complex mutual interaction. A model that combines the advantages of both in-vitro and in-vivo cultures is the ex-vivo model. The demonstration of the platelet derived growth factors effects through the ex-vivo human full-thickness skin culture model is a keystone to support the evidence of the PRP effectiveness, as it represents an objective, fast, reproducible, and ethical investigational method.
The incidence of chronic lower extremity (LE) wounds continues to increase. Lower limb amputations are associated with increased cardiovascular exertion, further decline in functional ability, and higher mortality rates. As such, there has been a shift towards limb salvage modalities. These include local debridement with advanced wound care, revascularization, bony reconstruction, and soft tissue reconstruction. Perioperative planning for soft tissue reconstruction requires careful consideration of several factors, including patient comorbidities, wound size and location, exposed underlying structures, and in the case of possible free flap, patency of donor and recipient vessels. This article reviews the perioperative factors that should be considered in preparation for successful soft tissue reconstruction of the LE.
Aim: This paper presents the latest surgical approaches for epispadias treatment in the pediatric population, as well as those for adolescent and adult populations after initial failed repair in childhood.
Methods: The retrospective study was conducted between March 2005 and May 2020 and included 18 patients with the mean age of 21 months (range 11-48 months) (Group A), who underwent primary epispadias repair and 15 patients with the mean age of 18 years (range 13-29 years) (Group B), who underwent redo surgery after failed epispadias repair in childhood. In Group A, the surgery was performed as a one-stage procedure using complete penile disassembly technique, while, in Group B, the surgery was done as a two-stage procedure and included complete straightening and lengthening of the penis, followed by urethral reconstruction. Penile straightening and lengthening were achieved by tunica albuginea incision and grafting. In Group A, the urethral plate was mobilized, transposed ventrally, and tubularized and augmented with vascularized preputial skin flap where needed. In Group B, the urethra was reconstructed either using the buccal mucosa graft and genital skin flaps or with tubularization of genital skin flaps. Successful treatment was defined as a functional and esthetically acceptable penis without complications.
Results: The mean follow-up was 88 months (range 15-197 months). Satisfactory results were achieved in 26/33 patients. Urethral fistula occurred in 4/18 patients from Group A and in 3/15 patients in Group B and was surgically repaired after four months. Skin dehiscence occurred in eight patients, five from Group A and three from Group B. Recurrent penile curvature was observed in 2/18 patients from Group A and required surgical correction and in 2/15 patients from Group B and was mild and did not need surgical repair. Eleven patients from Group B who filled out the International Index for Erectile Function reported satisfying erectile function, sexual desire, intercourse, and overall satisfaction.
Conclusion: Primary or redo epispadias repair is challenging even for experienced reconstructive urologists. Only radical surgical approach can lead to complete correction of all deformities and provide successful outcome.
Transgender men undergoing phalloplasty and metoidioplasty have a high rate of urethral stricture. Evaluation of stricture includes evaluation of symptoms and uroflow, cystoscopy, and retrograde urethrogram. Important anatomic differences between the phallus of cis-gender and transgender men increase the likelihood and complexity of treating urethral strictures in transgender men after surgery. Urethral strictures after masculinizing procedures are more likely to require open surgical treatment and recur after treatment. There is a paucity of data, but less invasive options such as dilation and urethrotomy have had minimal success. Open surgical options with a variety of techniques, including one-stage and two-stage techniques, have higher success rates in treating strictures, but there is minimal comparative data on outcomes. We present a review on management options for urethral reconstruction in transgender men and our data on urethroplasty for these patients.
Eyelid reconstruction remains one of the more challenging areas of the face to reconstruct due to its dynamic complexity. They play an essential role in protecting the globe, forming a barrier against trauma, excessive light, and pumping tears towards the nasolacrimal duct system. A critical understanding of the anatomy and soft tissue reconstructive options is essential to properly reconstruct the eyelid and maintain the functional and cosmetic components.
Lower extremity amputation is increasingly prevalent in the United States, with growing numbers of patients suffering from diabetes and peripheral vascular disease. Amputation has significant functional sequelae as more than half of patients are unable to ambulate at one year postoperatively. Improving mobility and decreasing chronic post-amputation pain can significantly improve the quality of life for these patients and reduce the cost burden on the healthcare system. Plastic and reconstructive surgery has been at the forefront of “reconstructive amputation”, in which nerve pedicles can be surgically guided to decrease painful neuroma formation as well as provide targets for myoelectric prosthesis use. We herein review post-amputation outcomes, epidemiology of chronic, post-amputation pain, and current treatments, including total muscle reinnervation and regenerative peripheral nerve interface, which are at the forefront of multidisciplinary treatment of lower extremity amputees.
Post-traumatic lymphedema (PTL) is a complex, debilitating, and potentially common disease which has received limited attention to date. The available literature is reviewed to identify injury patterns and critical lymphatic areas associated with the disease. A deeper understanding of these critical anatomic regions allows the reconstructive surgeon to potentially identify PTL patients earlier in order to apply surgical and nonsurgical interventions in the acute phase, improving lymphatic physiology and, ultimately, patient outcomes. Current diagnostic and treatment approaches are discussed in detail, with a focus on lymphatic microsurgical techniques developed and applied to PTL within the last decade.
Peripheral nerve injuries (PNI) in the lower extremity are an uncommon but highly morbid condition. Recent advances in our understanding of nerve physiology and microsurgical techniques have inspired renewed faith in nerve surgery and sparked a creative renaissance in the tools, approaches, and reconstructive schemas available to surgeons in the management of lower extremity PNIs. In this article, we review the literature and provide a principles-based approach for the surgical management of lower extremity PNIs with an emphasis on techniques for functional reconstruction after complete nerve injury. General principles in management include early diagnosis with electrodiagnostics and imaging, early surgical exploration, and opting for nerve and tendon transfers when primary reconstruction of the injured nerve is unfavorable (e.g., delayed reconstruction, unavailability of proximal or distal nerve stumps, or long regenerative distance). The goal of functional reconstruction should be to restore independent gait, so understanding the roles of major neuromuscular units during the gait cycle informs the selection of donor nerves and tendons for transfer. Based on these principles and literature to date, specific algorithms for surgical management are presented for femoral, sciatic, tibial, and common peroneal nerves. We recognize limitations of the current literature, namely the predominance of case series evidence, and call for the accrual of more patient data in surgical management of PNIs.
The use of body mass index (BMI) to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested. While BMI thresholds are often meant to be protective, restricting patients from access to surgery can also cause harm. There is a rationale for the continued use of BMI, but the inherent problems with it must also be recognized, including how weight stigma impacts patients’ access to gender-affirming surgery and influences clinical care. This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries, as well as analogous procedures, existing de facto BMI thresholds, and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss. BMI factors into surgical decision-making based on the existing literature, which demonstrates that high BMI is associated with increased surgical risk, including higher incidences of surgical site infections and poor wound healing, as well as the possibility of free flap complications, which are a component of certain genital procedures. This patient population is at higher risk for eating disorders, and it is prudent to find alternatives to requiring patient self-monitored weight management. The impacts of weight stigma should be considered when treating gender-affirming surgery patients, and further data and research are needed to augment shared decision-making and lead to practice change.
Aim: The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described. Factors include microsurgeon inexperience, inadequate center resources, and fear of historically described poor surgical outcomes. The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects.
Methods: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric (aged 18 and younger) lower extremity following traumatic etiology since 2005. Outcomes included flap failure, return to the operating room, and functional status, where available.
Results: Seven studies were deemed appropriate for inclusion, with a total of 243 flaps included. Motor vehicle and motorcycle accidents were greater than 75% of total etiology. Most defects involved the foot or ankle (65.1%). In total, perforator flaps compromised the majority of flaps (54%), with the most common being the anterolateral thigh, the scapular/parascapular, and deep inferior epigastric flaps. Less common perforators included the groin flap, tensor fascia lata, radial forearm, lateral arm, and thoracodorsal perforator flap. Muscle-based flaps were less common (46%), with the latissimus dorsi and rectus muscle flaps composing the majority. The most commonly used recipient vessel was the anterior tibialis (49.5%) and posterior tibialis vessels (45.3%). Most studies performed reconstruction within 7-10 days of presentation. There was a cumulative 6.5% flap failure rate.
Conclusion: Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes. Recent trends indicate increasing usage of perforator flaps. This study shows that based on existing data, free flap utilization for pediatric patients is an adequate modality for repair, and may warrant greater consideration moving forward.
Bulbar urethral ischemic necrosis (BUIN) is an iatrogenic entity resulting from repeated attempts at performing anastomotic urethroplasty for pelvic fracture urethral injuries. Etiologically speaking, BUIN is related to a compromised blood supply of the bulbar urethra, which normally relies on anterograde supply from bulbar arteries and retrograde supply from recurrent branches of dorsal penile arteries, through the glans. At each transection of the bulbar urethra, both the anterograde and retrograde supplies are compromised, increasing the risk of BUIN. Even though this term is widely used among reconstructive urologists, BUIN is orphan of an accepted scientific definition. We aim to report our personal perspective on BUIN, to identify factors associated with its occurrence, and to describe the management options in these patients.
Communication and coordination between orthopedic and plastic surgeons improve outcomes in severe extremity trauma. The “orthoplastics” approach to limb salvage incorporates priorities and skillsets from both fields. Prevention of infection, coordinated skeletal and soft tissue reconstruction, and communication during recovery and rehabilitation are key priorities. The purpose of this review is to describe the orthopedic trauma surgeon’s perspectives on lower extremity reconstruction, including initial management, techniques and timing for provisional and definitive skeletal reconstruction, and considerations for rehabilitation and orthotic use to optimize functional outcomes.
Limb loss is disabling and carries significant functional and psychological repercussions to both the individual and society. The numbers of amputees are forecasted to double by 2050 from vascular disease and diabetes alone. Europe has 4.66 million amputees (431,000 amputations per year) and the United States 2 million amputees (185,000 amputations per year). Microvascular expertise is now more commonplace, increasing the likelihood of limb salvage and replantation. Further reconstructive input can take advantage of nerve and tendon grafting/transfers, free tissue transfer, and complex bone reconstruction. When this strategy does not satisfy individual needs, such as that seen with unstable soft tissues, amputation may be requested or offered. In part, the decision for salvage, replantation, or amputation in the future is likely to be guided by the sophistication of limb substitutes. This review will introduce the growing domain of bionics and where research in this area may deliver a sought clinical need.
Local advancement flaps are a key tool in the armamentarium of the reconstructive surgeon. They can be used to repair small and large defects on all areas of the face with excellent skin color and texture match, limited donor site morbidity, and flexibility to hide scars. In this review, we outline common categories of advancement flaps and discuss common situations for their use.
Aim: Summarize the available data on midfacial virtual patient specific planning and patient specific implants, highlighting the financial costs and savings, and additionally emphasize the potential cost implications of transitioning to “in-house” virtual 3D modeling and printing.
Methods: Review of current literature.
Results: Current literature suggests cost benefits of virtual patient specific planning and patient specific implants in the form of improved ischemia time, better boney apposition between flaps, and reduced patient complications. This reduction of complications includes a reduction in blood loss and time spent in the intensive care unit from flap failure. Improved boney apposition results in a higher likelihood of boney union and a further reduction in failure and complications. Subjective benefits of virtual patient specific planning and patient specific implants are shown in the form of improved reconstructive surgeon mental energy. In-house production of 3D models and presurgical planning provides additional cost benefits for providers as they can produce viable models at a fraction of the price of that which is produced by industrial companies. Providers can also construct and use models in an expedient manner compared to industrial models, allowing for the opportunity to be utilized in more acute settings. The foundation of developing an in-house workflow is adequate funding, resources, and clinical volume. Facilities also must focus on appropriate quality and safety measures, as well as appropriate workflow development for adequate production of models.
Conclusion: Virtual patient specific planning and patient specific implants show benefits in midfacial reconstructive outcomes, resulting in realized financial and temporal gains for both patient and provider. These gains may be enhanced by moving to in-house planning and printing.
Post-traumatic lower extremity bone loss in the setting of high-energy trauma can occur acutely as a result of an open fracture and surgical debridement, or secondarily as a result of nonunion or infection. Several techniques have been described in the literature for the management of these bony defects, including non-vascularized bone grafts, vascularized bone grafts and distraction osteogenesis. Herein, the authors review the role of vascularized bone grafts in the management of post-traumatic bone loss in the lower extremity.
Lower extremity defects are a source of significant functional and psychosocial morbidity for pediatric patients and require complex reconstructions to restore form and function. The advent of microsurgical reconstruction along with advances in wound care techniques and technologies have empowered reconstructive surgeons to perform limb salvage surgery in patients that would traditionally require amputation; however, the indications for performing reconstructive surgery for complicated cases are not ironclad. While this is the case, applying the principles of lower extremity reconstruction in adults to the pediatric population is often sufficient to achieve a satisfactory outcome. This overview discusses the evaluation and management of soft tissue defects of the leg in pediatric patients.
Soft-tissue management and subsequent salvage of the lower extremity following trauma has long presented difficult challenges to the plastic surgeon. Trauma to the lower extremity can produce long-term sequelae consisting of psychological trauma, functional deficits, and increased costs to the healthcare system. Avoiding incorrect management is important, and is compounded by the fact that few guidelines exist on appropriate treatment and patient counseling. This study aims to describe the authors’ experience at a large limb salvage center in order to further delineate management strategies.
Reconstruction of head and neck defects is a delicate endeavor that poses numerous intrinsic and extrinsic challenges, which are currently magnified by rising health care costs and limitations in system resources. Current trends in the United States heavily favor the use of free tissue transfer over locoregional pedicles flaps (LRPF); however, the latter group is often undervalued, offering high utility, practicality, and cost-efficiency whilst providing equivalent results. The submental island flap and supraclavicular artery island flap are two LRPF that should be in the arsenal of the modern reconstructive surgeon.
Although urethral strictures have been known since antiquity, the surgical management of urethral strictures has undergone a great (re)evolution over the last six decades, both in the perception of the disease and in the surgical repair techniques, always presenting itself as a challenge for the surgeon and patient. Reconstruction of urethral stricture disease involving a combination of grafts and flaps consists of a group of complex procedures with specific clinical indications. The knowledge of these procedures by reconstructive urologists is both necessary and relevant. A thorough understanding of the anatomy, including blood supply, is a crucial proviso for the correct evaluation and successful management of urethral stricture disease. We discuss the main techniques and indications in combined graft and flap urethroplasties.
Vascularized composite allotransplantation (VCA) is a novel surgical practice that involves the transplantation of multiple tissue types as a functional unit without the primary purpose of extending life. While VCA of the upper extremity is becoming increasingly accepted and performed, VCA of the lower extremity remains largely unexplored despite its acknowledged potential value. There are inherent ethical concerns surrounding VCA that are dominated by a conflict between the principles of beneficence and maleficence. The primary question is whether the quality-of-life benefits to the patient outweigh the risks associated with long-term immunosuppression for a non-lifesaving procedure. In addition, the ethical conversation involves concerns regarding informed consent, donor autonomy, patient privacy and public disclosure, patient selection, and unique considerations in the pediatric patient. Lower extremity VCA has additional ethical issues compared to upper extremity VCA, as current lower limb prostheses provide excellent, near baseline function that upper limb constructs have not yet been able to achieve. In this review, we discuss the ethical challenges of lower extremity VCA using available evidence for the upper extremity. We also compare ethical considerations of VCA of the extremity with other surgical alternatives to limb loss - namely, limb salvage and replantation - and address how the conversation may be altered with further advancements in immunosuppression and prosthetic technology.
Reconstruction of the lower extremity is a complex task that has evolved greatly in both technique and indication over the past century. Early advances in treating traumatic lower extremity injuries focused on primary amputation to avoid the high mortality of infection. The introduction of antibiotics improved surgical debridement and local reconstructive options, enhancing the viability of lower extremities with simple and proximal defects. With the advent of microvascular surgery, free tissue transfer techniques provided a means to reconstruct more distal and complex problems. As these surgical techniques have continued to evolve, so too have indications for reconstruction, patient management and post-operative care-now with a greater emphasis on patient quality of life and limb function. The purpose of this article is to outline the evolution of lower extremity reconstruction, and how the standard of practice has changed over time.
Aim: Patients with Ehlers-Danlos Syndrome (EDS) are considered to have an increased risk for wound healing complications. Surgeons may therefore be hesitant to offer elective surgeries, including gender-affirming surgeries (GAS), to EDS patients. At our center, we frequently encountered patients presenting for GAS evaluation with the co-existing diagnosis of EDS. This study aims to establish the prevalence of EDS diagnosis in our GAS patients and compare their post-operative complications to patients without EDS diagnosis.
Methods: This is a single-institution retrospective case-control study on all patients who underwent GAS from 2016-2020. Data include EDS diagnosis, demographics, operation, and complications (including minor wound healing issues).
Results: Of 1363 patients presenting for GAS, 36 (2.6%) had EDS diagnoses and were matched with 108 control patients. Major complications requiring surgical intervention in the OR occurred in 6 patients (4.2%), (2.8% EDS vs. 5.4% controls; P = 0.63), while 8.3% of EDS and 14% of controls required minor interventions (P = 0.38). The rate of wound healing issues of any severity was 28% in EDS vs. 47% in control groups (P = 0.04).
Conclusion: The prevalence of EDS diagnosis in our patient population is 132 times the highest reported prevalence in the general population. Wound healing issues and the need for additional post-operative interventions in the group with EDS diagnosis were not significantly different from the control group. Our findings suggest that patients with a diagnosis of EDS undergoing GAS have comparable outcomes to patients without EDS. Concerns for post-operative complications should not be a barrier to offering GAS to patients presenting with an EDS diagnosis.
Aim: Soleus muscle flaps have traditionally been a reliable tool in the plastic surgeon’s armamentarium for lower extremity reconstruction and limb salvage. In the modern era, many surgeons prefer free flaps. This study sought to evaluate trends and outcomes of soleus flap reconstruction after lower extremity injury in a large cohort at a Level 1 trauma center.
Methods: This is an Institutional Review Board -approved, retrospective chart review that was undertaken at Los Angeles County + University of Southern California Medical Center from 2007 to 2021. Patient demographics, Gustilo-Anderson fracture classification, flap characteristics, and outcomes were collected and analyzed. Outcomes of interest included failure rates, postoperative complications, and long-term ambulatory status.
Results: Of 187 local leg flaps, 68 (36.4%) were soleus flaps, with 84% of soleus flaps performed prior to 2016. The flap loss rate was 0.0%. Eighteen (26.1%) flaps demonstrated > 1 complication, including osteomyelitis/hardware infection (n = 12), flap revision (n = 6), and amputation (n = 2). Long-term follow-up demonstrated 35.3% of patients ambulating independently after an average of 7.5 ± 7.2 months, with the remainder needing a wheelchair or walking assistance device.
Conclusion: Although soleus flap loss rate was 0%, the findings demonstrate more infections than expected; this must be considered in light of pre-existing patient comorbidities possibly deterring free flap placement. Additionally, our results reveal that only 16% of soleus flaps were performed after 2015. As surgeons consider the reconstructive ladder for lower extremity trauma, a rotational soleus muscle flap should not be overlooked in the modern era of free flap tissue transfers and might be a more optimal flap choice in certain patients with multiple comorbidities.
Advancements in microsurgical techniques have allowed for the salvage of extremities that would otherwise be amputated. Despite these improvements, mangling injuries of the lower extremity with concomitant open fracture continue to present a challenge for reconstructive surgeons. These injuries are further complicated by circumstances in which a single vessel is perfusing the foot after trauma (Gustilo 3C injuries). Although the foot may remain perfused in this instance, free flap coverage of open fractures with concomitant vascular injury requires careful planning to maintain a viable foot. The surgeon must adapt surgical plans based on both preoperative and intraoperative findings. In this review, we discuss current concepts and reconstructive techniques for performing free flap reconstruction in single-vessel lower extremities.
The landscape of available technology and surgical technique has changed over the last several decades, thus leading to changes in the peripheral nerve repair surgical algorithm. Neurorrhaphy is a common procedure; however, it is well recognized that nerve repair should be performed tensionless, thus preventing the ability to perform direct repair with a nerve gap. Historically, nerve gaps were repaired with autograft. However, autograft surgery has been associated with complications such as numbness and chronic pain, which left surgeons searching for alternatives. Nerve allografts were first utilized in the 1800s but failed due to the immune response. In the modern era, they were again utilized in the 1980s, but did not gain popularity because of the need for the use of immunosuppressants. It was evident through the 1990s that continued innovation in peripheral nerve repair was needed, as studies showed that only approximately 50% of patients with nerve gap repair achieved good or excellent outcomes. In the 2000s, the advent of an engineered nerve allograft (Avance® Nerve Graft) changed the landscape of peripheral nerve repair. Early clinical evaluation of Avance showed that adequate sensation was able to be achieved in nerve gaps up to 30 mm, providing an alternative to autografts. As engineered nerve allograft use became more conventional, studies showed 87.3% meaningful recovery in nerve gaps up to 50 mm. Furthermore, recent studies have shown that gaps between 50-70 mm have shown 69% meaningful recovery. While technology and surgical technique continue to improve, these results are promising for large nerve gap repair.
Aim: We analyzed the use of tubularized tunneled bladder mucosa graft (TBMG) and its application as a salvage procedure or as primary surgery for long urethroplasty in children and adolescents. Specific attention was given to a new method to harvest a long bladder mucosa graft through a minimal detrusotomy.
Methods: We analyzed the files of 10 patients who underwent TBMG urethroplasty at median age of 105 months (range 20-195 months). The indications were perineal hypospadias cripple in two, masculinizing genitoplasty for ovotesticular Ovotesticular Disorder of Sex Development (DSD) in two, perineal hypospadias in four, duplicated urethra in one, and complications of circumcision in one. Staged reconstruction was performed in all patients. The first stage was removal of all fibrous tissues and efficient treatment of curvature and skin coverage. After a minimal delay of one year, a free bladder mucosa graft was harvested through a minimal detrusotomy and tubularized. Tunneling of the graft was proceeded from the perineal urethrostomy to the glans.
Results: The graft was successfully harvested through the minimal detrusotomy approach for variable lengths of urethroplasty; the median length was 10.5 cm (range 8-16 cm). The median follow up was 61.7 months (range 18-160 months). TBMG was the last surgery with no redo in five cases (50%). Long stricture occurred in one case of primary perineal hypospadias and needed a redo staged surgery. Two patients performed self-dilatation for distal stenosis.
Conclusion: The tunneled bladder mucosa tube graft technique represents a good alternative for a long urethroplasty in patients with a paucity of healthy skin. The minimal detrusotomy technique for graft retrieval may reduce graft harvesting morbidity.
While the number of gender-affirming procedures continues to boom all over the world, resulting complications from genital surgeries are on the rise as well. This paper aims to review some of the most commonly described complications of gender-affirming vaginoplasties and provide our expert opinion on how to mitigate them based on the senior author’s experience. Specifically, poor cosmesis, soft tissues related complications, rectal and urethral injuries, neovaginal stenosis, as well as intraoperative and postoperative bleeding will be addressed.
Metoidioplasty consists of lengthening and straightening the hormonally hypertrophied clitoris. The goals of the procedure include masculinizing the external genitalia and enabling standing micturition. Metoidioplasty may be performed as a stand-alone procedure or an interval procedure prior to phalloplasty. While most often performed with urethral lengthening, metoidioplasty may also be performed as a “simple release” (i.e., without urethral lengthening). Secondary procedures typically include scrotoplasty and placement of testicular implants. While satisfaction with this procedure is high, complications can occur. Complications are commonly categorized as either urologic (i.e., strictures and fistula) or wound healing (i.e., wound disruption, infection, bleeding, etc.). This narrative review discusses postoperative outcomes, including both satisfaction and complications. Published data on complications include fistula and stricture rates from 0%-50% and 0%-63%, respectively. Overall satisfaction with appearance ranges from 48%-100%, and patient ability to void while standing ranges from 67%-100%. Metoidioplasty is a safe and effective procedure for transgender men. Further research regarding surgical techniques and outcomes will help reduce complications and improve overall patient satisfaction.
Radiotherapy-induced urethral strictures (RIUS) decrease quality of life and present a great challenge for surgical reconstruction, especially due to proximal location, compromised vascular supply, and poor wound healing. It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation. We review the pathophysiology, diagnostic workup, and disease-specific aspects of RIUS. Furthermore, we discuss several management alternatives such as excision and primary anastomosis, as well as techniques for open reconstruction with flaps. The most extensive techniques in the treatment of strictures include, for example, those using gracilis muscle flaps, as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing. In brief, RIUS represent a significant challenge. In carefully chosen patients, urethroplasty should be considered as a feasible and durable treatment. However, medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.
Symptomatic neuromas are an all-too-common complication following limb amputation or extremity trauma, leading to chronic and debilitating pain for patients. Surgical resection of symptomatic neuromas has proven to be the superior method of intervention, but traditional methods of neuroma resection do not address the underlying pathophysiology leading to the formation of a future symptomatic neuroma and lead to high reoperation rates. Novel approaches employ the physiology of peripheral nerve injury to harness the regeneration of nerves to their advantage. This review explores the underlying pathophysiology of neuroma formation and centralization of pain signaling. It compares the traditional surgical approach for symptomatic neuroma resection and describes three novel surgical strategies that harness this pathophysiology of neuroma formation to their advantage. The traditional resection of symptomatic neuromas is currently the standard of care for amputation patients, but new techniques including the regenerative peripheral nerve interface, targeted muscle reinnervation, and intraosseous transposition have shown promise in improving patient pain outcomes for postamputation pain and residual limb pain. Symptomatic neuromas are a chronic and debilitating complication following amputation procedures and trauma, and the current standard of care does not address the underlying pathophysiology leading to the formation of the neuroma. New techniques are under development that may provide improved patient pain outcomes and a higher level of care for symptomatic neuroma resection.
Aim: We investigated the clinical application of autologous chyle fat in the correction of sunken upper eyelid.
Methods: From November 2020 to October 2021, 89 cases of correction with autologous chyle fat to sunken upper eyelid were performed (with or without other cosmetic procedures related to the eyes). An appropriate amount of fat was extracted from the superficial layer of the patient’s thigh and processed to chyle fat. About 0.5-2.8 mL of fat was injected under the orbicularis oculi muscle (roof-retro orbicularis oculi fat) or in the area where the orbital septal fat exists from the outer orbital margin of the upper eyelid.
Results: In total, 59 patients were followed up for 1-11 months after surgery. No infection, necrosis, vascular embolism, upper eyelid lumpiness, fat calcification, or liquefaction occurred in all patients, while seven cases showed inadequate correction. The depression basically disappeared, the shape was relatively full, the youthfulness was greatly improved, and the satisfaction of patients was high during the follow-up period.
Conclusion: The correction with autologous chyle fat to sunken upper eyelid showed little trauma, short recovery periods, and satisfactory results, and it is worthy of being popularized and applied more widely.
The number of people with diabetes worldwide has reached epidemic proportions. Diabetics are well-known to have chronic nerve compressions, and the prevalence of compressions exceeds 50% in those with neuropathy. The loss of sensation in the feet of people with diabetic neuropathy is the primary cause of their ulceration and amputation, as well as pain. The aim of this article is to update the reader on the current status of lower extremity nerve decompression in patients with diabetic neuropathy. A review of the history and literature related to the current approach to the patient with chronic nerve compression plus diabetic neuropathy was undertaken. The current evidence is overwhelmingly clear, in diabetics with neuropathy and a positive Tinel sign over the tibial nerve at the tarsal tunnel, that decompression, by neurolysis of lower extremity nerves, can relieve pain, restore sensation, and prevent ulceration and amputation. Furthermore, economic cost-benefit analysis by the Markov technique demonstrates that lower extremity nerve compression is not only cost-effective compared to standard medical care, but also increases the quality of life and life expectancy. The remaining barriers to acceptance and implementation of this proven surgical approach must lie in the education of physicians in training and re-education of diabetes educators, primary care providers and endocrinologists.
Millions of people around the globe suffer peripheral nerve injuries caused by trauma and medical disorders. However, medical school curricula are profoundly deficient in peripheral nerve education. This lack of knowledge within the healthcare profession may cause inadequate patient care. We developed the Virtual Peripheral Nerve Academy (VPNA) as a reusable virtual learning environment to provide medical students with detailed education on the peripheral nervous system (PNS). Students are introduced to the PNS through virtual 3D rendering of the human body, wherein they visualize individual nerves through dissection and observe normal motor and sensory function associated with each nerve. PNS structures that are absent from traditional texts are included in this visualization, ranging from the innervation of joints to the normal anatomic variation required for differential diagnosis of pain after an injury. Detailed modules on peripheral nerve disorders allow students to observe pathophysiological mechanisms, associated symptomatology, and appropriate treatments. Students are briefed on a patient clinical case, then interact with a patient avatar to learn the appropriate diagnostics, including physical exam maneuvers and electrodiagnostic testing. Interactive modules on peripheral nerve surgeries detail surgical techniques. The VPNA data and analytics dashboards allow medical students and course instructors to assess skill improvement and identify specific learning needs. The built-in learner management system and availability on both computer-based and virtual reality platforms facilitate integration into any existing medical school curricula. Ultimately, this immersive technology enables every medical student to learn about the peripheral nervous system and gain competency in treating real-life nerve pathologies.
The management of chronic peripheral lymphedema benefits from a multidisciplinary approach in which magnetic resonance imaging (MRI) can play a key role. The imaging has been well described in the literature (including this journal), but the process for starting a novel imaging service line is complex. Participants in this process, including radiologists, imaging technical staff, information technologists, and revenue cycle managers, must be engaged and work in harmony to achieve success. The purpose of this article is to detail the building blocks and steps in starting a peripheral lymphedema MRI program, how our process evolved, and lessons learned along the way.
Despite significant advancements in neuroprosthetic control strategies, current peripheral nerve interfacing techniques are limited in their ability to facilitate accurate and reliable long-term control. The regenerative peripheral nerve interface (RPNI) is a biologically stable bioamplifier of efferent motor action potentials with demonstrated long-term stability. This innovative, straightforward, and reproducible surgical technique has shown enormous potential in improving prosthetic control for individuals with upper limb amputations. The RPNI consists of an autologous free muscle graft secured around the end of a transected peripheral nerve or individual fascicles within a residual limb. This construct facilitates EMG signal transduction from the residual peripheral nerve to a neuroprosthetic device using indwelling bipolar electrodes on the muscle surface. This review article focuses on the development of the RPNI and its use for intuitive and enhanced prosthetic control and sensory feedback. In addition, this article also highlights the use of RPNIs for the prevention and treatment of postamputation pain.
Aim: Dermal fillers are increasingly popular procedures. Inadvertent intraarterial injection of fillers, particularly with calcium hydroxylapatite (CaHA), can result in devastating consequences. A systemic review was performed to summarize management strategies to treat CaHA-associated vascular complications.
Methods: The methodology of this review was derived from The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). In addition, this paper presents a previously unreported case of a CaHA-associated vascular complication.
Results: There were 32 articles describing 42 cases, plus our case included in this review. There were 15 cases of vision complications, 23 cases of non-vision complications, and 5 experimental studies. The most common injection sites reported were nasal region for vision complications (45%) and nasolabial folds for non-vision complications (40%). Of the 38 human cases, the most prevalent treatment choice was steroids (24 cases, 63%). Complete or near complete improvement was reported in 83% of non-vision complications and 40% of vision complications. There was no noticeable homogeneity in the management strategies and outcomes of the patients. Of the 5 experimental studies, no clear consensus on treatments was found.
Conclusion: Vascular complications of CaHA are seemingly uncommon, but it is widely suspected that this is due to underreporting. While best management is prevention, preparation for a potential complication is equally important. Derived from CaHA literature, hyaluronic acid filler complication protocols, findings of this review, and personal experiences, this report proposes management strategies for CaHA-associated vascular complications. We hope these strategies provide a much-needed framework for injectors to refer to and utilize as needed.
This case report aimed to present the course of surgically combined comprehensive orthodontic treatment of a male adult with cleft lip and palate, showing a left alveolar cleft, lateral deviation of the major segment of the maxilla, and palatal transposition of the lateral incisor. Preoperatively, the midline of the upper central incisors was shifted by 7.0 mm to the right, the right lateral incisor showed palatal transposition, and the residual alveolar cleft was 6.5 mm. Segmental Le Fort I osteotomy of the major segment, and simultaneous bone grafting into the extended alveolar bone and former cleft region were performed at 18 years and 4 months of age. Thus, midline correction, alignment of the right lateral incisor, and cleft closure were achieved; no further prosthetic treatment was required.
Aim: Skin firmness is one of the key parameters to define skin quality and facial aging. Among the minimally invasive anti-aging strategies, hyaluronic acid (HA) injection is widely accepted to improve skin quality. While most of the available HA injectables are designed and intended for intradermal injection, a novel HA/sorbitol composition containing 2.6% high molecular weight hyaluronic acid stabilized by sorbitol was recently developed to be specifically injected into the adipose tissue to improve the quality of all skin layers, especially the skin firmness.
Methods: The HA/sorbitol composition was investigated versus product comparators in terms of biophysical properties, tolerance in subcutaneous tissue with in vivo implantation study, and skin firmness assessment on human skin explants.
Results: The HA/sorbitol composition was characterized by unique and differentiated biophysical properties, proper distribution and high tolerance of the gel composition into the adipose tissue, and the ability to efficiently improve skin firmness.
Conclusion: The HA/sorbitol composition represents a new attractive solution to treat facial skin aging with an injection strategy specifically targeting the adipose tissue instead of the dermis, to improve the quality of the skin.
Nerve transfers for peripheral nerve injuries have become increasingly popular over the past two decades. While techniques for ulnar nerve repair have been well-documented, more recent techniques for median and radial nerve branch reinnervation are still being explored. This review describes the outcomes of common and emerging techniques for reinnervation of the distal branches of the median and radial nerves.
Physiologic surgical options, including vascularized lymph node transplant and lymphovenous bypass are becoming increasingly popular interventions for the treatment of lymphedema of both the upper and lower extremities. Many different lymph node donor sites have been described, including submental, lateral thoracic, superficial groin, supraclavicular, and various intraabdominal sites. This paper describes a step-by-step approach to the harvest of vascularized lymph nodes from the supraclavicular area, which is the preferred donor site for most patients with both upper and lower extremity lymphedema.
Approximately 75% experience phantom (PLP), residual (RLP), or general (GLP) limb pain following lower extremity amputation. Targeted muscle reinnervation (TMR) is a peripheral nerve transfer that reroutes amputated nerves to motor endplates that can prevent or treat limb pain. This systematic review summarizes pain outcomes following primary and secondary treatment of lower extremity PLP, RLP, and GLP. Primary literature review of three databases - PubMed, EMBASE, MEDLINE - were used for all articles related to TMR and lower extremity limb pain, querying the same keywords: “targeted muscle reinnervation” AND “pain”. Citations were then reviewed and eliminated if only upper extremities were studied or the study lacked pain outcomes. Citations were categorized as primary or secondary TMR. Pain outcomes, including Numerical Rating Scales (NRS) and Patient-Reported Outcome Measurement Information System (PROMIS) Pain scores, were aggregated when appropriate. Ten studies met all inclusion and exclusion criteria after formal review for a total of 431 extremities, of which 79.1% (n = 341 limbs) were lower extremities. Average primary TMR PROMIS scores for PLP and RLP were lower than amputees without primary TMR. Average NRS scores and PROMIS Pain scores in secondary TMR demonstrated improvements in PLP, RLP, and GLP. Primary and Secondary TMR does prevent and improve PLP, RLP, and GLP; however, a minority of studies report quantifiable pain outcomes. All future TMR studies should include validated pain outcomes to better quantify the expected pain and quality of life improvements after lower extremity TMR.
Posttraumatic thumb defects result in significant functional impairment. Multiple reconstructive procedures have been described for the management and improvement of function. Compared with no treatment, all reconstructive methods are beneficial. Each of the available procedures may be more applicable under certain conditions, can offer great benefits, and have its own downsides as well. With a thorough assessment and meticulous technique, the results of thumb reconstruction can be excellent. We present a review of the current reconstructive procedures for traumatic thumb amputation.
Dermal fillers have become increasingly popular as a cosmetic treatment for facial rejuvenation. Although these injections are generally considered to be safe, as the number of injections has increased, so has the rate of complications. Ischemic complications of fillers include vision loss, ophthalmoplegia, skin necrosis, and cerebral infarction. Knowing the anatomy well is critical to optimally prevent and manage these serious complications. Prevention includes knowledge of the vascular anatomy of the facial area, as well as certain injection techniques such as aspiration, use of a smaller needle, and adoption of a larger cannula. The use of ultrasound has been a recent innovation in preventing and treating filler complications as well. The reversibility of fillers should also be considered when choosing a filler. Some hyaluronic acid (HA) fillers, including the newer ones on the market, are difficult to reverse and non-HA fillers and fat are irreversible. This review aims to discuss facial anatomy, the various ischemic filler complications, the prevention and management of these complications, and the relatively recent use of imaging as an adjunct.
Aim: Although vascularized lymph node transplantation (VLNT) has gained recognition as an effective treatment option for lymphedema, no consensus on the timing of transplant with other lymphatic procedures has been established. The aim of this study is to describe our institutional experience with VLNT, including our staged approach and report postoperative outcomes.
Methods: A retrospective review of patients who underwent VLNT for upper extremity lymphedema from May 2017 to April 2022 was conducted. Patients were divided into fat- or fluid-dominant phenotypes based on preoperative workup. Patients with a minimum of 12-month follow-up were included. Records were reviewed for demographic, intraoperative, and surveillance data.
Results: Twenty-three patients underwent VLNT of the upper extremity during the study period, of which eighteen met the study criteria. Nine patients had fluid-dominant disease and nine patients had fat-dominant disease and had undergone prior debulking at our institution. Fluid-dominant patients demonstrated slight reductions in limb volume and hours in compression, and improvement in quality-of-life scores at twelve months. Fat-dominant patients who underwent prior debulking had a slight increase in limb volume without a change in hours of compression, and demonstrated improvements in quality-of-life scores in nearly all subdomains. Overall, 17% of patients discontinued compression therapy entirely. Improvement in extremity edema was present in 83% of postoperative MRIs.
Conclusion: VLNT had varying effects on limb measurements while reliably improving quality-of-life and allowing for the potential of discontinuing compression. Utilizing a staged approach wherein debulking is performed upfront may be particularly beneficial for patients with fat-dominant disease.
Aim: Hyaluronic acid (HA) injectables have gained rapid acceptance for the treatment of skin rejuvenation. A novel HA/sorbitol composition intended for skin quality improvement containing 2.6% of high molecular weight HA stabilized by sorbitol was recently designed to be injected subcutaneously. The aim of this study was to assess the expression of biological markers of skin quality after administration of the composition.
Methods: The HA/sorbitol composition was evaluated after injection into the superficial adipose tissue with ex vivo cultured human skin explants versus a product comparator to study the general morphology of the skin tissues and the expression of HA, elastin, collagen type I, collagen type III, and fibrillin-1 in the dermal layer.
Results: The results demonstrate that the HA/sorbitol composition is able to boost the production of HA, elastin, collagen type I, collagen type III, and fibrillin-1 in the dermis while providing a proper quality of skin morphology.
Conclusion: The HA/sorbitol composition improved biological markers of skin quality in the dermis after product injection into the superficial adipose tissue. This novel composition can be considered as an attractive solution to treat skin aging by injecting a specific HA/sorbitol formulation to strategically target the subcutaneous tissue to improve the quality of the different layers of the skin.
Aim: Biosynthetic scaffolds represent cutting-edge therapeutic efforts for secondary lymphedema. In particular, nanofibrillar collagen scaffolds have shown efficacy in both preclinical and clinical contexts, and there has been growing interest in these scaffolds in recent years. This study systematically reviewed the current literature on nanofibrillar collagen scaffolds for lymphedema treatment to synthesize findings and highlight areas for further research.
Methods: This was a systematic scoping review of the literature on nanofibrillar collagen scaffolds for lymphedema treatment.
Results: Upon review of the literature, 32 relevant articles were identified, of which seven articles specifically investigating nanofibrillar collagen scaffolds were selected for inclusion. Of these articles, three investigated scaffold placement in small or large animal models, while four were clinical investigations ranging from case reports to retrospective cohort studies. Across all studies, scaffold implantation was associated with significant improvement in lymphedema symptoms compared to untreated controls, especially when used in combination with physiologic microsurgical procedures such as vascularized lymph node transfer. However, even when used alone or in combination with lymph node fragments, subcutaneous placement of these scaffolds improved lymphedema symptoms. Additionally, in a rodent model of lymphedema, scaffold placement at the time of lymph node harvest forestalled the development of lymphedema, highlighting the preventative capacity of these scaffolds as well.
Conclusion: Nanofibrillar collagen scaffolds have been demonstrated to effectively treat and/or prevent secondary lymphedema in both preclinical and clinical investigations. Ultimately, these scaffolds represent a promising intersection of tissue engineering and lymphedema therapy, and further clinical investigation is warranted.
Restoration of upper extremity function poses a unique surgical challenge. With considerations ranging from ensuring appropriate skeletal support and musculotendinous and ligamentous anatomy, restoring adequate vascularity and innervation, and providing sufficient soft tissue coverage, upper extremity injuries present a diverse range of reconstructive problems. Recent history has been marked by an expansion of novel techniques for addressing these complex issues. Sophisticated modalities, such as targeted muscle reinnervation, free functional muscle transfer, and vascularized composite allotransplantation, have become some of the most powerful tools in the armamentarium of the reconstructive surgeon. This review article aims to define the distinguishing features of each of these modalities and reviews some of their unique advantages and limitations.
Aim: Targeted muscle reinnervation (TMR) is a procedure pioneered to improve control of myoelectric prostheses and was fortuitously found to improve postamputation pain by transferring residual nerve ends from an amputated limb to reinnervate motor nerve units in denervated muscles. This study sought to perform a systematic review of the literature regarding the postamputation pain-related outcomes following TMR.
Methods: PubMed database was queried using the key term “targeted muscle reinnervation”. Articles were chosen based on the following criteria: (1) clinical studies on TMR; (2) greater than one subject; (3) studies were case-controls, comparative cohort analyses, controlled trials, or randomized controlled trials; and (4) studies included one or more outcomes of interest: prosthetic use and functionality, improvement or persistence of pain, indications, complications, donor nerves, and technical aspects of TMR.
Results: Overall, 9 studies including 101 upper extremity and 252 lower extremity nerve transfers were analyzed, with nerve transfer type, amputation location, and specific neurotizations reported. Four studies assessed the efficacy of TMR in addressing phantom limb pain (PLP) and residual limb pain (RLP), with 3 out of 4 studies reporting significant improvements in PROMIS (Patient Reported Outcome Measurement Information System) scores in TMR subjects compared to controls. Five additional studies did not analyze PROMIS scores but reported subjective improvements in pain outcomes.
Conclusion: Included studies demonstrated TMR had lower maximal pain and pain intensity, behavior and interference compared to the standard of care. Secondary TMR used to treat patients with established painful neuromas also reported improvement in pain compared to baseline.
Upper limb loss results in significant physical and psychological impairment and is a major financial burden for both patients and healthcare services. Current myoelectric prostheses rely on electromyographic (EMG) signals captured using surface electrodes placed directly over antagonistic muscles in the residual stump to drive a single degree of freedom in the prosthetic limb (e.g., hand open and close). In the absence of the appropriate muscle groups, patients rely on activation of biceps/triceps muscles alone (together with a mode switch) to control all degrees of freedom of the prosthesis. This is a non-physiological method of control since it is non-intuitive and contributes poorly to daily function. This leads to the high rate of prosthetic abandonment. Targeted muscle reinnervation (TMR) reroutes the ends of nerves in the amputation stump to nerves innervating “spare” muscles in the amputation stump or chest wall. These then become proxies for the missing muscles in the amputated limb. TMR has revolutionised prosthetic control, especially for high-level amputees (e.g., after shoulder disarticulation), resulting in more intuitive, fluid control of the prosthesis. TMR can also reduce the intensity of symptoms such as neuroma and phantom limb pain. Regenerative peripheral nerve interface (RPNI) is another technique for increasing the number of control signals without the limitations of finding suitable target muscles imposed by TMR. This involves wrapping a block of muscle around the free nerve ending, providing the regenerating axons with a target organ for reinnervation. These RPNIs act as signal amplifiers of the previously severed nerves and their EMG signals can be used to control prosthetic limbs. RPNI can also reduce neuroma and phantom limb pain. In this review article, we discuss the surgical technique of TMR and RPNI and present outcomes from our experience with TMR.