Background:. Chronic pain is a known complication following neurogenic thoracic outlet syndrome (nTOS) procedures, often resulting from supraclavicular nerve (SCN) injury and neuroma formation. Despite its clinical significance, there is limited literature on techniques to address the SCN in nTOS surgery. This study evaluates the use of regenerative peripheral nerve interface (RPNI) to mitigate neuropathic pain and reduce the risk of symptomatic neuroma formation when the SCN is divided during nTOS surgery. Methods:. A retrospective review was conducted of 12 patients who underwent supraclavicular nTOS surgery with RPNI of the SCN between 2021 and 2024. The SCN and its branches were coapted to an autologous free muscle graft, secured within its epimysium, and folded to complete the RPNI. The omohyoid was used as the donor muscle in most cases. Results:. A total of 12 patients (median age 32 y) underwent SCN RPNI at the time of nTOS decompression. The omohyoid was used in 7 cases, the scalene in 3, the trapezius in 1, and the sternocleidomastoid in 1. At follow-up (mean 11 mo), most patients reported improvement in nTOS-related symptoms. Five patients, all with prior nTOS surgery, reported persistent discomfort reflecting ongoing nTOS rather than new focal supraclavicular neuropathic pain. No clinical symptoms characteristic of supraclavicular neuromas were observed at short-term follow-up. Conclusions:. RPNI of the SCN is a feasible adjunct during supraclavicular nTOS when the nerve must be divided, with no clinically evident neuromas observed at short-term follow-up. Larger controlled studies with standardized outcome measures are needed to clarify its independent impact.

Heterotopic ossification (HO) is a rare but recognized complication of adductor longus tears, and the factors that predispose patients to its development are not well characterized. The purpose of this study was to identify factors associated with the development of HO following adductor longus tears and to describe outcomes after surgical management. A retrospective review was conducted of 132 patients surgically treated for adductor longus tears by a single surgeon between January 2016 and January 2025. Patients were classified by tear severity (partial versus complete) and by symptom chronicity (acute versus chronic, using a six-month cutoff). HO was identified on MRI or CT. All patients had failed prior conservative management and underwent surgical excision, with pain and range of motion assessed at six months postoperatively. Of the 132 patients, 87 had partial tears and 45 had complete tears. HO was identified in 10 of 45 patients (22

Background:In obese patients, short-term outcomes after endoscopic versus open carpal tunnel release (CTR) are not well defined. Methods:TriNetX was queried for obese adults undergoing CTR. Propensity score matching (1:1) on demographics, body mass index, comorbidities, and medication exposures produced balanced cohorts for 30-day outcomes (8850 per group) and 90-day outcomes (8606 per group). Outcomes were assessed at 30 and 90 days and reported as risk ratios (RRs) with 95% confidence intervals (CIs). Results:Endoscopic CTR demonstrated lower wound morbidity than open CTR, with reduced wound disruption at 30 days (RR 0.339, 95% CI 0.207-0.555) and 90 days (RR 0.341, 95% CI 0.224-0.519) and reduced infection at 30 days (RR 0.237, 95% CI 0.133-0.425) and 90 days (RR 0.341, 95% CI 0.223-0.524) (all P < 0.001). At 90 days, endoscopic CTR also showed lower sepsis (RR 0.500, P = 0.014) and pulmonary embolism (RR 0.435, P = 0.024). Readmissions were lower at 30 days (RR 0.414, 95% CI 0.372-0.461) and 90 days (RR 0.513, 95% CI 0.472-0.556) (both P < 0.001). Revision procedures were more common at 30 days (RR 1.276, 95% CI 1.172-1.389) and 90 days (RR 1.178, 95% CI 1.097-1.265) (both P < 0.001). Differences in deep vein thrombosis, acute kidney injury, myocardial infarction, stroke, pneumonia, urinary tract infection, stiffness, and mortality were not significant. Conclusions:Endoscopic CTR in obese patients is associated with fewer short-term wound complications and fewer readmissions than open CTR, though revision procedures were more frequent.

Background: Dupuytren contracture (DC) is a fibroproliferative disorder of the palmar fascia, commonly managed through enzymatic collagenase injections or surgical interventions such as fasciotomy or fasciectomy. This study aims to compare clinical outcomes and complication rates between patients undergoing collagenase injection and those receiving surgical treatment for DC. Methods: Using the TriNetX US Collaborative Network, a retrospective cohort study was conducted including 8444 patients who underwent collagenase injection and 8444 propensity score–matched patients who received surgical management for DC. Key outcomes assessed included postoperative infection, hematoma, nerve injury, reintervention rates, functional outcomes (occupational therapy utilization), and emergency room visits. Risk differences, risk ratios, and odds ratios (OR) were calculated using risk analysis. Follow-up was 180 days. Results: Collagenase treatment was associated with significantly lower risks of postoperative infection (0.7% versus 1.4%, OR 0.49, P < 0.001) compared to surgery. Nonetheless, collagenase was associated with a significantly higher reintervention rate (31.7% versus 16.2%, OR 2.40, P < 0.001). No significant differences were observed in iatrogenic nerve injuries (0.2% in both groups), hematoma (0.3% in both groups), functional outcomes (35.9% versus 36.7%, P = 0.284), or emergency room utilization (24.6% versus 24.5%, P = 0.915). Conclusions: Collagenase injection for DC is associated with fewer short-term complications but nearly doubles the risk of reintervention compared to surgical management.

BACKGROUND:Perineural scarring after peripheral nerve surgery is a known cause of persistent pain and reoperation. Brachial plexus decompression for neurogenic thoracic outlet syndrome (nTOS) carries a particularly high risk given the extent of dissection, scalenectomy, and the constant motion of the cervicothoracic region. Recurrence rates after complete decompression range from 7% to 30%. VersaWrap (Alafair Biosciences) is a bioresorbable hyaluronic acid/alginate hydrogel that physically blocks fibroblast access while allowing nutrient diffusion to the nerve. Its use has not previously been reported in brachial plexus surgery. METHODS:We reviewed 94 patients who underwent supraclavicular brachial plexus decompression for nTOS at a single institution between 2014 and 2025. Forty-nine received VersaWrap around the brachial plexus trunks after neurolysis; 45 underwent the same procedure without a wrap. Primary outcomes were persistent neuropathic pain and reintervention for nTOS. Secondary outcomes included paresthesias, opioid use past 5 days, wound complications, and device-related adverse events. RESULTS:Mean follow-up was 12 months for the entire cohort. Persistent neuropathic pain occurred in 2 VersaWrap patients (4.1%) versus 3 controls (6.7%). Reintervention was required in 1 VersaWrap patient (2%) versus 2 controls (4.4%). Postoperative paresthesias were noted in 4 VersaWrap patients (8.2%) versus 3 controls (6.7%). Opioid use beyond 5 days occurred in 2 VersaWrap patients (4.1%). No device-related complications were observed. CONCLUSIONS:VersaWrap was safe and well tolerated. Rates of persistent pain and reoperation were numerically lower in the VersaWrap group, though the study was not powered to detect significant differences. These results support further prospective evaluation of hydrogel barriers in high-risk peripheral nerve surgery.

Background: The work relative value units (wRVUs) system was established as a quantifier of physician labor, technical skill, medical decision-making, and training time required to complete a surgical procedure; hence, more challenging operations should theoretically result in higher reimbursement or compensation. Our purpose was to highlight the discrepancies between insurance-based reconstructive and fee-for-service aesthetic procedures based upon dollar/unit time. Methods: We analyzed national data from the American College of Surgeons National Surgical Quality Improvement Program, Aesthetic Surgery Databank, and Centers for Medicare and Medicaid Services to compare reimbursement for 8 reconstructive microsurgery and 3 aesthetic procedures and assessed operative times and reimbursement rates, then calculated “relative value unit per unit time” to measure compensation efficiency. Results: This difference in remuneration translates to a 4.7× difference, with an overwhelming gap of $25.26 per minute between microsurgical reconstructive and aesthetic cases. These findings suggest that aesthetic cases are more profitable considering the compensation per unit time. Based on national rates of reimbursement, there is a large discrepancy between reimbursement in microsurgical reconstructive procedures and aesthetic procedures. Conclusions: We demonstrated that complexity and time are not directly related to compensation.

Background: In reconstructive plastic surgery, the need for comprehensive research and systematic reviews is apparent due to the field's intricacies, influencing the evidence supporting specific procedures. Although Chat-GPT's knowledge is limited to September 2021, its integration into research proves valuable for efficiently identifying knowledge gaps. Therefore, this tool becomes a potent asset, directing researchers to focus on conducting systematic reviews where they are most necessary. Methods: Chat-GPT 3.5 was prompted to generate 10 unpublished, innovative research topics on breast reconstruction surgery, followed by 10 additional subtopics. Results were filtered for systematic reviews in PubMed, and novel ideas were identified. To evaluate Chat-GPT's power in generating improved responses, two additional searches were conducted using search terms generated by Chat-GPT. Results: Chat-GPT produced 83 novel ideas, leading to an accuracy rate of 83%. There was a wide range of novel ideas produced among topics such as transgender women, generating 10 ideas, whereas acellular dermal matrix (ADM) generated five ideas. Chat-GPT increased the total number of manuscripts generated by a factor of 2.3, 3.9, and 4.0 in the first, second, and third trials, respectively. While the search results were accurate to our manual searches (95.2% accuracy), the greater number of manuscripts potentially diluted the quality of articles, resulting in fewer novel systematic review ideas. Conclusion: Chat-GPT proves valuable in identifying gaps in the literature and offering insights into areas lacking research in breast reconstruction surgery. While it displays high sensitivity, refining its specificity is imperative. Prudent practice involves evaluating accomplished work and conducting a comprehensive review of all components involved.

Chronic pain is a frequent and notable complication after inguinal hernia repair, it has been extensively studied but its management and diagnosis are still difficult. The cause of chronic pain following inguinal hernia surgery is usually multifactorial. This case series highlights the utility of MRI neurography (MRN) in evaluating the damage to inguinal nerves after a hernia repair, with surgical confirmation of the preoperative imaging findings. A retrospective review was performed on patients who underwent inguinal mesh removal and triple denervation of the groin. Inclusion criteria included MRI Neurography. All patients underwent surgical exploration of the inguinal canal for partial or complete mesh removal and triple denervation of the groin by the same senior surgeon. A total of nine patients who underwent triple denervation were included in this case series. MRN was then performed on 100% of patients. The postoperative mean VAS score adjusted for all patients was 1.6 (SD p), resulting in a 7.5 score difference compared to the preoperative VAS score (p). Since chronic groin pain can be a severely debilitating condition, diagnosis and treatment become imperative. MRN can detect direct and indirect signs of neuropathy even in the absence of a detectable compressive cause aids in management and diagnosis by finding the precise site of injury, and grading nerve injury to aid pre-operative assessment for the nerve surgeon. Thus, it is a valuable diagnostic tool to help with the diagnosis of nerve injuries in the setting of post-inguinal hernia groin pain.

Background: Targeted muscle reinnervation has been adopted as a strategy for the management and prevention of phantom limb pain and symptomatic neuroma formation for patients undergoing lower extremity amputation. The procedure is often performed by surgeons different from those performing the amputation, creating scheduling dilemmas. The purpose of this study was to analyze historic trends in lower extremity amputation scheduling in a single hospital system to evaluate if offering routine immediate targeted muscle reinnervation is practical.Methods: De-identified data over a five-year period for all patients undergoing lower extremity amputation were collected. The data gathered included the specialty performing the amputation, weekly distribution of cases, start time, and end time, among others.Results: A total of 1549 lower extremity amputations were performed. There was no statistically significant difference in average number of below-the-knee amputations (172.8) and above-the-knee amputations (137.4) per year. Top specialties performing amputations were vascular surgery (47.8%), orthopedic surgery (34.5%), and general surgery (13.85%). No significant difference was noted in the average number of amputations across the week, per year. Most cases started between 6 am and 6 pm (96.4%). The average length of stay after surgery was 8.26 days.Conclusions: In a large, nontrauma hospital system, most lower extremity amputations are performed during typical working hours and are evenly distributed throughout the week. Understanding peak timing of amputations may allow for targeted muscle reinnervation to be performed concurrently with amputation procedure. Data presented will be a first step to optimizing amputation scheduling for patients in a large nontrauma health system.

Background:Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction.Methods:Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success.Results:Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps.Conclusions:The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

Purpose: To evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy. Methods: Public posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person’s symptoms and concerns were collected from each post. Descriptive statistics were used to analyze the data. Results: Twenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Sex information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and 4 posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery. Conclusions: A high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy preoperatively. Clinical Relevance: Identifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes.

Gravina, Paula MD; Farhat, Souha MD; Jaraki, Dima MD; De la Fuente Hagopian, Alexa MD; Echo, Anthony MD; Dinh, Tue A. MD Author Information

PURPOSE: To validate crowdsourced perceptions of breasts with their alignment to the aesthetics of breast augmentation patients. METHODS: A prospective cross-sectional study was performed using participants enrolled through the Amazon-Mechanical Turk crowdsourcing platform (Amazon Web Services, Amazon, Seattle, WA) to obtain participant opin-ions of how closely patient breasts aligned with previously obtained results of 4 ideal breast characteristics. Outcomes were reported based on the correlation between breast attractiveness and alignment to ideal breast characteristics, both before and after breast implant procedures. RESULTS: 2306 responses from 737 participants reported patient photograph alignment with ideal breast projection proportion (1.0) as having the highest correlation to opin-ions of heightened aesthetic beauty (R = 0.98, P < 0.001), and ideal nipple direction (front) as having the lowest correlation to aesthetic beauty (R = 0.90, P < 0.001). Younger age groups (18-24) and participants with a high school diploma or less rated patients as less attractive, while mar-ried and wealthy individuals reported higher attraction levels. CONCLUSION: Crowdsourcing

Purpose: To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques. Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury. Results: Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively. Conclusions: The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries.

Background Abdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown. Methods Using a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed. Results A total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST. Conclusion CS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.

Transection of the supraclavicular nerve (SCN) through supraclavicular incisions can lead to debilitating neuroma formation. Targeted muscle reinnervation (TMR) proved to be an effective technique for the prevention and treatment of neuroma. In this case series, we propose the TMR of the SCN to the motor branch of the omohyoid muscle (OM) to prevent the formation of neuroma and avoid chronic pain at the supraclavicular area after thoracic outlet syndrome (TOS) procedures. A total of 10 patients underwent the procedure. Dissection of the SCN and its branches was performed through a supraclavicular incision. The branches were transected close to the clavicle. The inferior belly of the OM was identified and its motor branch isolated. Coaptation of the SCN branches with the motor branch of the OM was performed under the microscope and the wound was closed in layers. All the patients denied pain or hypersensitivity at the supraclavicular area on follow-up. In summary, the motor branch of the OM is a viable recipient for the TMR of the SCN and can prevent and treat painful neuromas at the supraclavicular area with minimal morbidity.

The exposure and dissection of the recipient internal mammary artery and veins is a critical component of free flap breast reconstruction. Prolonged retraction of the mastectomy skin flaps is required to expose the third or fourth intercostal space for dissection and the microanastomosis. The superomedial vector of retraction is the most critical and the most challenging to achieve. This exposure is traditionally achieved with a myriad of techniques including self-retainers, lone star hooks or ring self-retainers, active assistant-based Richardson or Deaver retraction, or some combination thereof. The following adage applies: When multiple techniques exist for solving the same problem, there is no perfect technique. All are subject to retractor migration, inadequate exposure, or assistant fatigue. Intermittent removal or replacement of retraction is often necessary to avoid prolonged tension on the mastectomy skin flaps, which can be laborious and time consuming. We present a novel technique using the WalterLorenz electromechanical arm (Zimmer Biomet; Jacksonville, Fla.). In our experience, this simple, low-profile device has revolutionized internal mammary vessel exposure and expedited operative times. The device is secured and draped on the top of the bed. A sterile interface secures to standard retractors and its range of motion allows for bilateral use from a single position. Single button functionality releases the arm for 360-degree range of motion. A standard medium Richardson retractor is used with the device to provide consistent medial retraction (Fig. 1). The device can be rapidly released and repositioned. Its low profile easily allows two-surgeon access for the microanastomosis. This technique exceeds the amount of exposure provided by other methods, facilitates rapid intermittent tension release on the skin flaps, reduces operative time, and removes the need for an assistant.Fig. 1.: The robotic arm with the Richardson retractor provides excellent internal mammary vessel exposure.The device is listed at $45,000 for purchase with a recurring cost of $250 for the single-use sterile drape. Its applications extend beyond internal mammary vessel exposure. It has also been found to function exceptionally well for retraction of the anterior compartment in free fibula harvest, adductor retraction for profunda artery perforator flap harvest, and rectus femoris retraction for anterolateral thigh pedicle dissection. Cutting-edge techniques in breast oncology have resulted in an increase in nipple-sparing mastectomies through inframammary or short vertical incisions.1,2 In addition, multiflap reconstructions (stacked deep inferior epigastric or deep inferior epigastric perforator/profunda artery perforator flaps) are increasingly used for adequate volume and projection.3 These techniques require improved exposure for anterograde or retrograde anastomosis as well as smaller incisions through which to achieve it. At our institutions, this device has become indispensable for exposure and microanastomosis and has been adopted by each surgeon after a single first-use trial. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.