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While many single-institution studies have investigated the relationship between surgical technique and perioperative outcomes in craniosynostosis surgery, the Pediatric National Surgical Quality Improvement Program (Peds NSQIP) allows this on a nationwide scale. By analyzing the CPT codes associated with craniosynostosis surgery, insight can be gained not only into the prevalence of certain procedures, but into their effects on perioperative outcomes. Patients with craniosynostosis were selected from the Peds NSQIP database (2012-2018) based on the corresponding ICD-9 code. CPT codes associated with single suturectomy or craniectomy with and without the use of distractors/springs, and craniotomy with and without the use of bone grafts, were used to further identify patient groups. Outcome variables included operative time, hospital stay, and blood transfusions. Analysis showed that patients undergoing single suturectomies or extensive cranioplasties with distractor/spring placement had shorter operative times, shorter hospital stays, and decreased incidence of blood transfusions. The use of bone grafts was associated with significantly longer operative times and a higher incidence of blood transfusions, as well as higher volumes of blood transfused. Distractor/spring use can facilitate shorter operative times and decreased rates of blood transfusion. Bone grafting, while commonly used, is associated with increased rates of blood transfusion. Despite the statistical significance of these results, the nonspecific nature of the craniosynostosis-specific CPT codes severely limited the extent of analysis possible. Updating the CPT coding system would allow for greater utility of NSQIP in determining nationwide procedure-specific outcomes.

The radial forearm free flap (RFFF) is associated with troublesome donor site morbidity related to split thickness skin grafting (STSG). The radial forearm snake flap with primary closure of the donor site may reduce donor site complications.Single institution, retrospective cohort study comparing rates of delayed donor site wound healing and tendon exposure in 52 patients undergoing radial forearm snake flap and 95 patients undergoing conventional RFFF with STSG closure of the donor site.Tendon exposure occurred in zero (0%) patients undergoing snake flap and four (4.2%) patients undergoing conventional RFFF (0/52 vs. 4/95; p = 0.297). Delayed wound healing occurred in zero (0%) patients undergoing snake flap and 19 (20.0%) patients undergoing conventional RFFF (0/52 vs. 19/95; p 0.001).The radial forearm snake flap provides an alternative to conventional RFFF harvest, which enables primary donor site closure with reduced rates of delayed donor site healing.

Breast cancer affects 1 in 8 women. As the treatment of breast cancer evolves, breast reconstruction does as well. Implant-based reconstructions are increasing, leading to increased use of acellular dermal matrix (ADM) for better implant positioning. Acellular dermal matrices are derived from cadaveric skin and are processed to be immunologically inert. However, ADM can be costly and can have complications such as seroma and infection. This has led to the development of dermal autografts. These were first used in postmastectomy breast reconstruction in women with redundant breast skin that was deepithelialized and used for lower pole coverage of tissue expanders and implants. This evolved into harvesting dermal autografts from the abdomen. Later studies evaluated the use of meshed dermal autografts. Histological analysis of ADM versus dermal autografts shows that there are increased vessels within dermal autografts compared with ADM. This potentially contributes to the decreased complication rate seen with autografts. In addition, one study showed equivalent results in aesthetic outcomes and capsular contracture between ADM and dermal autograft. Analysis of cost has shown that ADM is significantly more costly than harvesting a dermal autograft. Physician reimbursement is also higher for dermal autografts. This review article seeks to summarize key studies that highlight the feasibility of using dermal autografts in breast reconstruction.

Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

Background:. Despite significant improvements in zone II flexor tendon repair over the last 2 decades, function-limiting complications persist. This article describes 2 novel repair techniques utilizing flexor digitorum superficialis (FDS) autografts to buttress the flexor digitorum profundus (FDP) repair site without the use of core sutures. The hypothesis being that the reclaimed FDS tendon autograft will redistribute tensile forces away from the FDP repair site, increasing overall strength and resistance to gapping in Zone II flexor tendon injuries compared with the current clinical techniques. Methods:. Two novel FDP repair methods utilizing portions of FDS have been described: (1) asymmetric repair (AR), and (2) circumferential repair. Ultimate tensile strength and cyclical testing were used to compare novel techniques to current clinical standard repairs: 2-strand (2-St), 4-strand (4-St), and 6-strand (6-St) methods. All repairs were performed in cadaveric sheep tendons (n = 10/group), by a single surgeon. Results:. AR and circumferential repair techniques demonstrated comparable ultimate tensile strength to 6-St repairs, with all 3 of these techniques able to tolerate significantly stronger loads than the 2-St and 4-St repairs (P < 0.0001). Cyclical testing demonstrated that AR and circumferential repair were able to withstand a significantly higher total cumulative force (P < 0.001 and P = 0.0064, respectively) than the 6-St, while only AR tolerated a significantly greater force to 2-mm gap formation (P = 0.042) than the 6-St repair. Conclusion:. Incorporating FDS as an autologous graft for FDP repair provides at least a comparable ultimate tensile strength and a significantly greater cumulative force to failure and 2-mm gap formation than a traditional 6-St repair.

Background Preparation of the internal mammary artery (IMA) is a critical step in autologous breast reconstruction. Intraoperatively, there is limited opportunity for residents to practice this skill. Porcine models provide highly realistic simulation for vascular surgery; however, use of live laboratory pigs is expensive, inconvenient, and offers limited opportunity for repetitive training. We aimed to develop an inexpensive and effective training model for IMA preparation. This article describes creation of a novel microsurgical model using cadaveric chest walls of Wisconsin Miniature Swine embedded in a modified mannequin thorax and augmented with a blue-blood perfusion system. Methods Anatomic comparison: five porcine chest walls were dissected, and various anatomic measurements were made for anatomic comparison to existing human data in the literature. Model assembly: the chest wall is prepared by cannulating the proximal and distal ends of the internal mammary vessels with angiocatheters, which are then connected to the blue-blood perfusion system. The model is assembled in four layers including: (1) a mannequin thorax with a window removed to expose the first to fourth intercostal spaces, bilaterally, (2) a layer of foam simulating fat, (3) the perfused pig chest wall, and (4) a second mannequin shell placed posteriorly for support. Results The porcine chest walls are similar to humans with regards to vessel size and location. This model can be assembled quickly, with a one-time approximate cost of $55.00, and allows for six training sessions per specimen. The model allows residents to practice the key steps of IMA preparation including dissection, elevation of perichondria, and vascular anastomosis while working at a depth that closely simulates the human thorax. Continuous blue-blood perfusion provides immediate feedback on anastomosis quality. Conclusion Overall, this novel model can provide inexpensive and realistic simulation of internal mammary vessel preparation and anastomosis.

Introduction While debate persists over how to best prevent or treat amputation neuromas, the more pressing question of how to best marry residual nerves to state-of-the-art robotic prostheses for naturalistic control of a replacement limb has come to the fore. One potential solution involves the transposition of terminal nerve ends into the medullary canal of long bones, creating the neural interface within the bone. Nerve transposition into bone is a long-practiced, clinically relevant treatment for painful neuromas. Despite neuropathic pain relief, the physiological capacity of transposed nerves to conduct motor and sensory signals required for prosthesis control remains unknown. This pilot study addresses the hypotheses that (1) bone provides stability to transposed nerves and (2) nerves transposed into bone remain physiologically active, as they relate to the creation of an osseointegrated neural interface. Methods New Zealand white rabbits received transfemoral amputation, with the sciatic nerve transposed into the femur. Results Morphological examination demonstrates that nerves remain stable within the medullary canal, while compound nerve action potentials evoked by electrical stimulation of the residual nerve within the bone could be achieved at 12 weeks (p Conclusion Transposed nerves retain a degree of physiological function suitable for creating an osseointegrated neural interface.

Pediatric obstructive sleep apnea, characterized by partial or complete obstruction of the upper airway during sleep, is associated with multiple adverse neurodevelopmental and cardiometabolic consequences. It is common in healthy children and occurs with a higher incidence among infants and children with craniofacial anomalies. Although soft-tissue hypertrophy is the most common cause, interplay between soft tissue and bone structure in children with craniofacial differences may also contribute to upper airway obstruction. Snoring and work of breathing are poor predictors of obstructive sleep apnea, and the gold standard for diagnosis is overnight polysomnography. Most healthy children respond favorably to adenotonsillectomy as first-line treatment, but 20 percent of children have obstructive sleep apnea refractory to adenotonsillectomy and may benefit from positive airway pressure, medical therapy, orthodontics, craniofacial surgery, or combined interventions. For children with impairment of facial skeletal growth or craniofacial anomalies, rapid maxillary expansion, midface distraction, and mandibular distraction have all been demonstrated to have therapeutic value and may significantly improve a child's respiratory status. This Special Topic article reviews current theories regarding the underlying pathophysiology of pediatric sleep apnea, summarizes standards for diagnosis and management, and discusses treatments in need of further investigation, including orthodontic and craniofacial interventions. To provide an overview of the spectrum of disease and treatment options available, a deliberately broad approach is taken that incorporates data for both healthy children and children with craniofacial anomalies.

Background Arterial bypass and interposition grafts are used routinely across multiple surgical subspecialties. Current options include both autologous and synthetic materials; however, each graft presents specific limitations. Engineering artificial small‐diameter arteries with vascular cells derived from induced pluripotent stem cells could provide a useful therapeutic solution. Banking induced pluripotent stem cells from rare individuals who are homozygous for human leukocyte antigen alleles has been proposed as a strategy to facilitate economy of scale while reducing the potential for rejection of induced pluripotent stem cell–derived transplanted tissues. Currently, there is no standardized model to study transplantation of small‐diameter arteries in major histocompatibility complex–defined backgrounds. Methods and Results In this study, we developed a limb‐sparing nonhuman primate model to study arterial allotransplantation in the absence of immunosuppression. Our model was used to compare degrees of major histocompatibility complex matching between arterial grafts and recipient animals with long‐term maintenance of patency and function. Unexpectedly, we (1) found that major histocompatibility complex partial haplomatched allografts perform as well as autologous control grafts; (2) detected little long‐term immune response in even completely major histocompatibility complex mismatched allografts; and (3) observed that arterial grafts become almost completely replaced over time with recipient cells. Conclusions Given these findings, induced pluripotent stem cell–derived tissue‐engineered blood vessels may prove to be promising and customizable grafts for future use by cardiac, vascular, and plastic surgeons.

Background Bioelectric medicine seeks to modulate neural activity via targeted electrical stimulation to treat disease. Recent clinical evidence supports trigeminal nerve stimulation as a bioelectric treatment for several neurological disorders; however, the mechanisms of trigeminal nerve stimulation and potential side effects remain largely unknown. The goal of this study is to optimize the methodology and reproducibility of neural interface implantation for mechanistic studies in rodents. New method(s) This article describes a single incision surgical approach to the infraorbital nerve of rats and mice and the supraorbital nerve in rats for trigeminal nerve stimulation studies. This article also presents the use of cortical evoked potentials and electromyography as methods for demonstrating effective engagement between the implanted electrode and target nerve. Comparison with existing method(s) A number of surgical approaches to the infraorbital nerve in rats exist, many of which are technically difficult. A simple, standardized approach to infraorbital nerve in rats and mice, as well as the supraorbital nerve of rats is integral to reproducibility of future trigeminal nerve stimulation studies. Conclusion The infraorbital nerve of rats and mice can be easily accessed from a single dorsal incision on the bridge of the nose that avoids major anatomical structures such as the facial nerve. The supraorbital nerve is also accessible in rats from a single dorsal incision, but not mice due to size. Successful interfacing and engagement of the infra- and supraorbital nerves using the described methodology is demonstrated by recording of evoked cortical potentials and electromyography.

Summary:. The most commonly used approach for a greater occipital nerve decompression is through a vertical midline incision, with multiple authors reporting favorable long-term outcomes. A transverse approach to the occipital nerves has been described, yet it does not include the use of fat flaps to insulate the decompressed nerves. In this study, we describe the use of a single transverse incision with modified “W” fat flaps to decompress both the greater and lesser occipital nerves. This allows for wider exposure of the nerves without the need for an additional incision to access the lesser occipital nerve. The described technique provides increased reach and versatility of the fat flap, allowing for coverage over a longer course of the nerve and further cephalad, close to the bony skull base. In addition, the fat flaps cover the greater occipital nerve closer to its native position, as opposed to bringing the nerve into a subcutaneous position. This, theoretically, keeps the nerve in a more protected deep position and technically makes it easier to avoid any tendency for kinking the nerves while wrapping them with the fat flap. Our experience has demonstrated that this modified technique is not only safe but also efficacious in affecting a statistically significant reduction (70% improvement, P = 0.004) in migraine headache index and HIT-6 scores. This study provides further evidence that nerve decompression for headache following the principles described by Guyuron is an efficacious and reproducible procedure and that a proper nerve decompression is effective in reducing headache.

Background Chronic stability and high degrees of selectivity are both essential but somewhat juxtaposed components for creating an implantable bi-directional PNI capable of controlling of a prosthetic limb. While the more invasive implantable electrode arrays provide greater specificity, they are less stable over time due to compliance mismatch with the dynamic soft tissue environment in which the interface is created. New Method This paper takes the surgical approach of transposing nerves into bone to create neural interface within the medullary canal of long bones, an osseointegrated neural interface, to provide greater stability for implantable electrodes. In this context, we describe the surgical model for transfemoral amputation with transposition of the sciatic nerve into the medullary canal in rabbits. We investigate the capacity to create a neural interface within the medullary canal histolomorphologically. In a separate proof of concept experiment, we quantify the chronic physiological capacity of transposed nerves to conduct compound nerve action potentials evoked via an Osseointegrated Neural Interface. Comparison with Existing Method(s) The rabbit serves as an important animal model for both amputation neuroma and osseointegration research, but is underutilized for the exploration neural interfacing in an amputation setting. Results Our findings demonstrate that transposed nerves remain stable over 12 weeks. Creating a neural interface within the medullary canal is possible and does not impede nerve regeneration or physiological capacity. Conclusions This article represents the first evidence that an Osseointegrated Neural Interface can be surgically created, capable of chronic stimulation/recording from amputated nerves required for future prosthetic control.

Summary:. Symptomatic neuroma after major extremity amputation is a challenging clinical problem for which there are many described treatment options. Neuroma excision and implantation into the medullary canal of long bones offers durability and insulation, and minimizes chronic pain. Another challenge in amputees is impaired function and an ongoing need for accessible and functional prostheses that are “bidirectional,” in that they provide both fine motor control and sensory feedback. Drawing on clinical experience with neuroma implantation into the medullary canal of long bones, the authors propose a novel neural interface whereby a terminal nerve end is redirected into the medullary canal of a nearby long bone and interfaced with an electrode array. The osseointegrated neural interface aims to exploit electrical signals from peripheral nerves to control advanced prosthetic devices for amputees. The purpose of this article is to present 2 clinical cases of nerve translocation into bone that serve as the clinical foundation of the osseointegrated neural interface as an innovative interface for prosthetic control.

Background Selection of recipient vessels for head and neck microvascular surgery may be limited in the previously dissected or irradiated neck. When distal branches of the external carotid artery (ECA) are unavailable, additional options for arterial inflow are needed. Here we propose high ligation of the ECA and transposition toward the lower neck as an alternative. Methods After obtaining institutional approval, patients who underwent head and neck tumor resection and simultaneous free flap reconstruction were identified over a 5-year period. Patients whose recipient artery was listed in the operative report were included. Chart review was performed to identify patient demographics, operative details, and patient and flap complications. In cases where the ECA was used, the artery was traced distally with care taken to protect the hypoglossal nerve. The ECA was then divided and transposed toward the lower neck where an end-to-end microvascular anastomosis was performed. Results The recipient artery used for head and neck microsurgery was available for 176 flaps, and the facial (n = 127, 72.2%) and external carotid (n = 19, 10.8%) arteries were most commonly used. There were 0 flap thromboses in the ECA group compared to 3 flap thromboses that occurred with other recipient arteries (P = 1.00). No cases of first bite syndrome or hypoglossal nerve injury were identified. Conclusions The ECA may be transposed toward the lower neck and used for end-to-end microvascular anastomosis without complication of hypoglossal nerve injury or first bite syndrome. This method may be considered an alternative in patients with limited recipient vessel options for head and neck microsurgery. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Background Radial forearm free flaps are a versatile option for head and neck reconstruction, but often complicated by donor-site problems including skin-graft loss and wound breakdown. We introduce the radial forearm “snake” flap as a technique enabling primary donor site closure and compare wound healing outcomes to flap donor sites requiring split thickness skin graft (STSG) closure. Patients and Methods A review of all radial forearm free flaps harvested over a 5-year period was performed. We identified 18 radial forearm snake flaps whose donor sites were closed primarily. These flaps were designed as a long, narrow ellipse parallel to the forearm. An additional 57 forearm flaps were identified whose donor sites were closed with STSGs. Patient demographics, free flap survival rates, and wound healing complications were compared. Results The survival rate for radial forearm snake flaps was 100% compared to 98.2% for wider radial forearm flaps (P = 1.00). There were 8 tendon exposures at the donor site, all of which occurred in patients whose donor sites were closed with STSGs. Delayed wound healing occurred in 1 radial forearm snake flap donor site (5.6%) compared to 18 (31.6%) donor sites closed with STSGs (P = 0.03). Conclusions Radial forearm snake flaps are useful for reconstruction of small to medium size defects of the oral cavity and oropharynx and enable primary donor site closure. Flap success rates are not compromised by raising a radial forearm snake flap and rates of delayed healing of the flap donor site are significantly reduced compared to forearm flap donor sites closed with STSGs. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Background Abdominal component separation is used commonly for closure of midline abdominal wounds. The value of each step in reducing tension has not been studied. Our aim was to test whether component separation decreases tension in the midline closure and to quantify the value of each procedural step. Study Design Tension required to bring the rectus muscle to midline was measured using tensiometry after subcutaneous dissection (step 1), external oblique muscle release (step 2), separation of the internal and external oblique muscles (step 3), and internal oblique muscle release (step 4). Measurements were taken in the upper, middle, and lower thirds of the abdominal midline. Distance to midline was also measured after each surgical step. Tension (measured as percent change) and distance were analyzed using Student's t -test with significance set at p Results In 41 hemi-abdominal defects, tension decreased in middle, upper, and lower thirds of the abdomen by 22.5%, 24.3%, and 34.8% after step 1; 33.4%, 31.8%, and 39.8% after step 2; 26.5%, 22.2%, and 27.4% after step 3; and 33.2%, 28.2%, and 23.5% after step 4. Mean distance change was 0.97 cm, 1.97 cm, 2.22 cm, and 2.59 cm after steps 1 to 4, respectively. Conclusions This study shows through a quantitative measure of tension that all steps of the component separation procedure decrease wound tension to variable degrees, with the release of the external and internal oblique muscles being the more effective steps. An internal oblique release is a useful and simple adjunct to the classical component separation procedure.

Radial forearm free flaps are a versatile option for head and neck reconstruction, but often complicated by donor-site problems including skin-graft loss and wound breakdown. We introduce the radial forearm "snake" flap as a technique enabling primary donor site closure and compare wound healing outcomes to flap donor sites requiring split thickness skin graft (STSG) closure.A review of all radial forearm free flaps harvested over a 5-year period was performed. We identified 18 radial forearm snake flaps whose donor sites were closed primarily. These flaps were designed as a long, narrow ellipse parallel to the forearm. An additional 57 forearm flaps were identified whose donor sites were closed with STSGs. Patient demographics, free flap survival rates, and wound healing complications were compared.The survival rate for radial forearm snake flaps was 100% compared to 98.2% for wider radial forearm flaps (P = 1.00). There were 8 tendon exposures at the donor site, all of which occurred in patients whose donor sites were closed with STSGs. Delayed wound healing occurred in 1 radial forearm snake flap donor site (5.6%) compared to 18 (31.6%) donor sites closed with STSGs (P = 0.03).Radial forearm snake flaps are useful for reconstruction of small to medium size defects of the oral cavity and oropharynx and enable primary donor site closure. Flap success rates are not compromised by raising a radial forearm snake flap and rates of delayed healing of the flap donor site are significantly reduced compared to forearm flap donor sites closed with STSGs. © 2014 Wiley Periodicals, Inc. Microsurgery 37:6-11, 2017.

Although the anatomy of the individual pectoralis major and minor muscles has been described previously, never before has the anatomic relationship between these muscles been investigated.The authors identify the anatomic relationship of the costal origins of the pectoralis major and minor muscles.Bilateral thoracic wall dissection was completed in 102 cadavers. In each dissection, the chest wall soft tissue was removed, and the distance between costal origins of the pectoralis major and the pectoralis minor muscles was measured.In 49 female and 53 male cadavers, 202 pectoralis major muscles were lifted to expose the costal origins of the pectoralis major and minor muscles. Distances between pectoralis major and pectoralis minor muscles were separated into 3 categories: less than 1 cm, between 1 and 3 cm, and greater than 3 cm. Forty-nine (24%) pectoralis muscle dissections displayed a distance of less than 1 cm between costal muscle origins. Eighty-three dissections (41%) showed an intermediate distance of between 1 and 3 cm, while the remaining 70 (35%) were over 3 cm. No significant difference was observed in these percentages with regard to sex. Ten cadavers displayed asymmetry in pectoralis muscle origin distance. Eight specimens displayed shared fibers between pectoralis major and minor muscles.The anatomic relationship between the costal origin of the pectoralis major and minor muscles is highly variable. Understanding this spatial relationship has important implications for cosmetic and reconstructive breast surgery.

We report the radiological findings of severe bilateral jugular foraminal stenosis along with anomalous basicranial venous drainage in a child with a history of complex nonsyndromic craniosynostosis. CT with 3D reconstructions and MR venography revealed that the lateral sinuses were draining transosseously through several markedly enlarged emissary veins. The main route of transverse and sigmoid sinus drainage was through large mastoid emissaries to the deep cervical veins. There was additional drainage of these mastoid emissaries into the vertebral and paravertebral plexuses as well as into venous collaterals which subsequently reconstituted the internal jugular veins. Basicranial venous anomalies are common among children with complex craniosynostosis, and although they may not resemble intracranial vascular outflow deficiencies, they can pose significant surgical risks. This case emphasizes the need for proper clinical assessment and documentation of anomalous basicranial venous anatomy to facilitate management of complex craniosynostosis patients.