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Background: Ever since their introduction, tissue expanders for breast reconstruction have undergone a gradual evolution from remote port expanders to the integrated port expanders commonly in use today. Integrated port expanders have been widely adopted because of their ease of use and reliability, and though the convenience of integrated port expanders over remote port expanders is clear, a side-by-side comparison of complications has not been performed. A same-surgeon, same-institution study was conducted comparing the complication rates of remote versus integrated tissue expanders. Methods: A retrospective review was conducted of 107 patients who underwent breast reconstruction with tissue expanders. Remote tissue expanders were used in 21 consecutive patients (n = 42) and integrated port tissue expanders in 86 consecutive patients (n = 128). Patients who had received prior or concurrent breast irradiation were excluded from the study. Overall complications were compared, followed by complications that were broken down according to mechanical and infectious complications. Results: Fisher’s exact test demonstrated a statistically significant increase in the rate of overall complications in remote port expanders compared with integrated port expanders (19% vs 7%; P = .024). Similarly, a statistically significant difference in the rate of mechanical complications between the 2 groups was found (7% in remote vs 0.8% in integrated, P = .047). When the rates of infectious complications were compared between the 2 groups, however (12% in remote vs 6% in integrated), no significant difference could be found (P=.312). Conclusion: In this retrospective review of prosthetic breast reconstructions, increased overall complicationswere observedwith remote tissue expanders that were mainly mechanical in nature. The higher rate of infection observed in the remote port group was not statistically significant. Our study shows that remote port expanders do in fact have a higher complication rate than integrated port expanders. This should be taken into account when considering the use of remote port expanders in certain clinical scenarios. [ABSTRACT FROM AUTHOR]

Background: Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour.It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid. Objectives: The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve. Methods: Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks. Results: Most often, the IOF's location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women. Conclusions: A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve. [ABSTRACT FROM AUTHOR]

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented. [ABSTRACT FROM AUTHOR]

Objective: Basal joint arthritis is a common cause of pain and disability, particularly in elderly women. Corticosteroid injection with splinting provides a reliable long-term relief for patients with mild arthritis. Proper location of the basal joint with anatomic landmarks can facilitate diagnosis and treatment of basal joint arthritis while avoiding inadvertent injury to local structures. The purpose of this study is to identify bony anatomic landmarks for basal joint injections and aid clinicians in avoiding inadvertent injury to surrounding structures on the radial side of the wrist. Methods: Twenty fresh cadaveric wrists were dissected with the aid of loupe magnification. The distal edge of the radial styloid and the palpable dorsal aspect of the thumb metacarpophalangeal joint were used as bony anatomic landmarks for the identification of the basal joint along a longitudinal vector. Measurements of the distance from our anatomic landmarks to the basal joint space were recorded. The locations of the radial artery and the superficial branch of the radial nerve were noted in relation to the borders of the anatomic snuffbox at the basal joint level. Results: The basal joint of the thumb is located 2.44 ± 0.34 cm distal to the distal edge of the radial styloid, and 4.47 ± 0.29 cm proximal to the metacarpophalangeal joint. At the level of the basal joint, the radial artery is found 0.76 ± 0.12 cm dorsal to the extensor pollicis brevis tendon. The first branch of the superficial branch of the radial nerve is volar to the abductor pollicis longus tendon in 84% of the specimens and courses over the abductor pollicis longus tendon in 16%. Conclusion: The basal joint of the thumb is approximately 2.4 cm distal to the radial styloid and 4.5 cm proximal to the metacarpophalangeal joint. Placement of a needle in the basal joint space immediately dorsal to extensor pollicis brevis tendonwhile applying longitudinal traction on the thumb is more likely to avoid damage to the radial artery and the superficial branch of the radial nerve. [ABSTRACT FROM AUTHOR]

Objective: Stenosing tenosynovitis of the thumb flexor tendon sheath is also known as trigger thumb. It is an inflammatory process that involves the flexor tendon sheath at the A1 pulley. Successful percutaneous or open treatment of trigger thumb depends on the ability of the clinician to properly predict the location of the A1 pulley. Longitudinal anatomic landmarks can facilitate safe treatment for the trigger thumb while circumventing injury to the neurovascular bundles. Methods: Fourteen fresh cadaveric hands were dissected to identify surface landmarks corresponding to the oblique course of the flexor pollicis longus tendon at the level of the A1 pulley. Results: The longitudinal landmarks for the A1 pulley of the thumb are the palpable hook of the hamate and the midline of the thumb interphalangeal (IP) crease. Other bony prominences, such as the pisiform bone did not serve as effective landmarks while the thumb was in an abducted position. Conclusion: we encourage the use longitudinal anatomic landmarks to predict the location of the thumb A1 pulley. The hook of the hamate and the midline at the palmar interphalangeal crease are reliable landmarks for safe release of the A1 pulley while avoiding inadvertent injury to adjacent structures. [ABSTRACT FROM AUTHOR]

Background: Breast reconstruction techniques have focused increasingly on using autologous tissue, with emphasis being placed on employing muscle sparing adipocutaneous flaps to reduce abdominal wall complications such as hernias, bulges, weakness, and length of hospital stay. The result has been the emergence of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction. Isolating perforator vessels challenges most surgeons. We describe surface anatomical landmarks to predict the location of the deep inferior epigastric artery (DIEA) and its perforators to aid in the efficient elevation of this flap. Methods: Ten fresh hemi-abdomens were dissected with loupe magnification. The DIEA and its perforators were identified, and measurements in relation to the rectus muscle, xiphoid, umbilicus, and pubis were taken. Statistical analysis was undertaken to determine distance ratios to account for variance in patient size. Results: Average distance from the xiphoid to umbilicus was 18.2 ± 1.27 cm. The distance from the umbilicus to pubis was 14.9 ± 2.3 cm. The vertical distance from the umbilicus to the DRJ (DIEA rtctus junction) was 10.45 ± 1.58 cm, and the vertical distance from the level of the umbilicus to where the first DIEA perforator traverses the RAM was 7.4 ± 1.64 cm. The distance between the umbilicus and the DRJ is approximately 0.7 times the distance between the umbilicus and the pubic symphysis. The distance between the umbilicus and the first perforator is approximately 0.5 times the distance between the umbilicus and the pubic symphysis. Conclusions: Knowledge of anatomical landmarks can aid the surgeon in more efficiently harvesting the DIEP flap. Surface landmarks along the abdominal midline coupled with normalizing ratios can aid surgeons in predicting the location of the DIEA and its first perforator. The DIEA crosses the rectus at approximately two thirds of the distance between the umbilicus and pubis, and the first perforator can reliably be located at one half of this distance. [ABSTRACT FROM AUTHOR]

Background: Ever since their introduction, tissue expanders for breast reconstruction have undergone a gradual evolution from remote port expanders to the integrated port expanders commonly in use today. Integrated port expanders have been widely adopted because of their ease of use and reliability, and though the convenience of integrated port expanders over remote port expanders is clear, a side-by-side comparison of complications has not been performed. A same-surgeon, same-institution study was conducted comparing the complication rates of remote versus integrated tissue expanders. Methods: A retrospective review was conducted of 107 patients who underwent breast reconstruction with tissue expanders. Remote tissue expanders were used in 21 consecutive patients ( n = 42) and integrated port tissue expanders in 86 consecutive patients ( n = 128). Patients who had received prior or concurrent breast irradiation were excluded from the study. Overall complications were compared, followed by complications that were broken down according to mechanical and infectious complications. Results: Fisher's exact test demonstrated a statistically significant increase in the rate of overall complications in remote port expanders compared with integrated port expanders (19% vs 7%; P = .024). Similarly, a statistically significant difference in the rate of mechanical complications between the 2 groups was found (7% in remote vs 0.8% in integrated, P = .047). When the rates of infectious complications were compared between the 2 groups, however (12% in remote vs 6% in integrated), no significant difference could be found ( P = .312). Conclusion: In this retrospective review of prosthetic breast reconstructions, increased overall complications were observed with remote tissue expanders that were mainly mechanical in nature. The higher rate of infection observed in the remote port group was not statistically significant. Our study shows that remote port expanders do in fact have a higher complication rate than integrated port expanders. This should be taken into account when considering the use of remote port expanders in certain clinical scenarios.

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.