BackgroundDespite indications of a close interaction between the trigeminal (CN V) and facial nerve (CN VII) within the buccinator muscle, a combination of anatomical dissection and histological analysis has not been reported.MethodsFive formalin-fixed and fresh-frozen hemifaces were dissected to reveal the buccal fat pad, the buccinator muscle, and anastomotic connections between CN V and CN VII within it. Samples were taken for histological processing and immunostaining.ResultsBranches of CN V and CN VII formed pronounced sensorimotor anastomotic connections in and surrounding the buccinator muscle. These findings were histologically evident with close intramuscular coupling of sensory and motor fibers. There was an evident but gradual shift from motor to sensory fibers in the interconnections when analyzing them from the side of CN V toward the side of CN VII and vice versa.ConclusionsThese results further elucidate connections between CN V and CN VII and their possible role in proprioception of the facial muscles.

Objective Until today, the true pathophysiology of hemorrhoidal disease (HD) has not yet been unraveled. More and more evidence guides us towards the hypothesis that reduced connective tissue stability is associated with a higher incidence of hemorrhoids. The present study aimed to compare the quantity and quality of collagen, and vessel morphometrics, in patients with symptomatic HD compared with normal controls. Methods Twenty-two samples of grade III and grade IV HD tissue from patients undergoing a hemorrhoidectomy between January 2004 and June 2015 were included in the study group. Samples of 15 individuals without symptomatic HD who donated their body to science and died a natural death served as controls. The quantity and quality of anal collagen, and anal vessel morphometrics were objectified. The quality of collagen was subdivided in young (immature) and old (mature) collagen. Results Patients with HD had an increased percentage of total anal collagen (62.1 ± 13.8 versus 18.7 ± 14.5%; p = 0.0001), a decreased percentage of young collagen (0.00009 ± 0.00008 versus 0.0008 ± 0.0008%; p = 0.001), and a smaller surface area of the anal vessels (795.1 ± 1215.9 micrometre2 versus 1219.0 ± 1976.1; p = 0.003) compared with controls. The percentage of old collagen did not differ between the control and study groups (0.588 ± 0.286% versus 0.389 ± 0.242%; p = 0.06). Conclusion The outcomes of the present study suggest that alterations in anal collagen composition may play a role in the formation of hemorrhoids.

Background: Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex. Methods: The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses–compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist. Results: Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast skin is innervated by anterior cutaneous branches and lateral cutaneous branches of the second through sixth and the nipple/nipple-areola complex primarily by anterior cutaneous branches and lateral cutaneous branches of the third through fifth intercostal nerves. The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve supply the largest surface area of the breast skin and nipple/nipple-areola complex. The lateral cutaneous branch of the fourth intercostal nerve is the most consistent contributory nerve to the nipple/nipple-areola complex (pooled prevalence, 89.0 percent; 95 percent CI, 0.80 to 0.94). Conclusions: The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.

Cervical facet joint pain syndrome accounts for a great amount of cervical pain worldwide. This study aims to provide updated knowledge of cervical facet joint innervation with new anatomical findings. Twenty-seven cervical facet joints and their innervating structures were dissected from five halves of three human neck specimens. Histologic staining was used to confirm that the samples were nervous tissues, and all samples were documented with photography. Histology: Thirty-six assumed facet joint branch samples were obtained and stained. Twenty-two of these were confirmed to be nervous tissue. Therefore, 61% of the samples were identified as facet joint branches. Of all samples, 28% were not nerves. Dissection: At least one medial branch was clearly identified at each dissected cervical level. At some cervical levels, more than one medial branch was found. Anatomical differences, such as a plexus-like innervation in the high cervical region, were observed. Direct facet joint branches were also discovered. These branches originate directly from the dorsal root of the spinal nerve and were independent from medial branches during their direct pathway toward the facet joint. Direct cervical facet joint branches were identified and a more diverse innervation pattern than previously described of the cervical facet joints was found.

BACKGROUND:Sensory nerve coaptation in autologous breast reconstruction positively affects sensory recovery in the reconstructed breast. However, patient-reported outcomes are lacking and no conclusions on the clinical relevance of nerve coaptation could be drawn. The aim of this study was to evaluate the clinical relevance of nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction.METHODS:A prospective cohort study was conducted of patients undergoing innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Patients completed a BREAST-Q questionnaire at a minimum of 12 months' follow-up in combination with either a preoperative questionnaire or a questionnaire at 6 months' follow-up. The physical well-being of the chest domain was the primary outcome and patients answered additional sensation-specific questions. Sensation was measured using Semmes-Weinstein monofilaments.RESULTS:In total, 120 patients were included (65 innervated and 55 noninnervated reconstructions). A clinically relevant difference was found in BREAST-Q scores in favor of patients with innervated reconstructions in general and for delayed reconstructions specifically. Patients with sensate breast reconstruction more often reported better and pleasant sensation.CONCLUSIONS:This study demonstrated that nerve coaptation in DIEP flap breast reconstruction, specifically in delayed reconstruction, resulted in clinically relevant improved patient-reported outcomes on the physical well-being of the chest domain of the BREAST-Q and that better sensation was perceived. However, the BREAST-Q does not address sensation adequately, and the introduction and validation of new scales is required to confirm the clinical relevance of nerve coaptation reliably.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

BACKGROUND CONTEXT: Adult spinal deformity patients treated operatively by long-segment instrumented spinal fusion are prone to develop proximal junctional kyphosis (PJK) and failure (PJF). A gradual transition in range of motion (ROM) at the proximal end of spinal instrumentation may reduce the incidence of PJK and PJF, however, previously evaluated techniques have not directly been compared. PURPOSE: To determine the biomechanical characteristics of five different posterior spinal instrumentation techniques to achieve semirigid junctional fixation, or "topping-off," between the rigid pedicle screw fixation (PSF) and the proximal uninstrumented spine. STUDY DESIGN: Biomechanical cadaveric study. METHODS: Seven fresh-frozen human cadaveric spine segments (T8 -L3) were subjected to ex vivo pure moment loading in flexion-extension, lateral bending and axial rotation up to 5 Nm. The native condition, three-level PSF (T11-L2), PSF with supplemental transverse process hooks at T10 (TPH), and two sublaminar taping techniques (knotted and clamped) as one- (T10) or two-level (T9, T10) semirigid junctional fixation techniques were compared. The ROM and neutral zone (NZ) of the segments were normalized to the native condition. The linearity of the transition zones over three or four segments was determined through linear regression analysis. RESULTS: All techniques achieved a significantly reduced ROM at T10-T11 in flexion-extension and axial rotation relative to the PSF condition. Additionally, both two-level sublaminar taping techniques (CT2, KT2) had a significantly reduced ROM at T9-T10. One-level clamped sublaminar tape (CT1) had a significantly lower ROM and NZ compared with one-level knotted sublaminar tape (KT1) at TM-TH. Linear regression analysis showed the highest linear correlation between ROM and vertebral level for TPH and the lowest linear correlation for CT2. CONCLUSIONS: All studied semirigid junctional fixation techniques significantly reduced the ROM at the junctional levels and thus provide a more gradual transition than pedicle screws. TPH achieves the most linear transition over three vertebrae, whereas KT2 achieves that over four vertebrae. In contrast, CT2 effectively is a one-level semirigid junctional fixation technique with a shift in the upper rigid fixation level. Clamped sublaminar tape reduces the NZ greatly, whereas knotted sublaminar tape and TPH maintain a more physiologic NZ. Clinical validation is ultimately required to translate the biomechanics of various semirigid junctional fixation techniques into the clinical goal of reducing the incidence of proximal junctional kyphosis and failure. CLINICAL SIGNIFICANCE: The direct biomechanical comparison of multiple instrumentation techniques that aim to reduce the incidence of PJK after thoracolumbar spinal fusion surgery provides a basis upon which clinical studies could be designed. Furthermore, the data provided in this study can be used to further analyze the biomechanical effects of the studied techniques using finite element models to better predict their post-operative effectiveness. (C) 2021 Elsevier Inc. All rights reserved.

www.PRSJournal.com 281 From the Department of Plastic, Reconstructive, and Hand Surgery, GROW—the School for Oncology and Developmental Biology, and the Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center; and the Department of Anatomy and Embryology, Maastricht University. Received for publication September 28, 2019; accepted July 16, 2020. Presented at the 10th Congress of World Society for Reconstructive Microsurgery, in Bologna, Italy, June 12 through 15, 2019; and presented in part at the 2019 Barcelona Breast Meeting, in Barcelona, Spain, March 13 through 15, 2019. Copyright © 2020 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000007547 The lateral thigh perforator flap, based on the tissue of the upper lateral thigh, has been introduced as an excellent alternative for autologous breast reconstruction in cases when the abdomen is not suitable as a donor site.1–3 The main indication for a lateral thigh perforator flap is having insufficient abdominal tissue, followed by a previous deep inferior epigastric perforator (DIEP) flap breast reconstruction or abdominoplasty, or a patient’s preference for the upper lateral thigh as the donor site.3 Despite the great aesthetic appearance of the reconstructed breast, the breast often remains numb. Besides restoring the aesthetics of the breast, restoring the sensation has increasingly become a goal of autologous breast reconstruction. The positive effect that sensation of the breast has on the patient-rated quality of life after Jop Beugels, M.D. Sander M. J. van Kuijk, Ph.D. Arno Lataster, M.Sc. René R. W. J. van der Hulst, M.D., Ph.D. Stefania M. H. Tuinder, M.D., Ph.D.

Background The gluteal region is one of the many alternative donor sites for autologous breast reconstruction. However, the harvest of the gluteal flap is rather difficult, and the major drawback of gluteal flaps has been the need for position changes for flap harvest and inset. A new approach of a gluteal flap is introduced, based on the septocutaneous perforators of the superior gluteal artery: the septocutaneous gluteal artery perforator (Sc-GAP) makeover flap. Methods A prospective study was performed in Maastricht University Medical Center between January 2018 and December 2019. Patients who underwent a Sc-GAP makeover flap breast reconstruction in the Maastricht University Medical Center and have had preoperative magnetic resonance angiography (MRA) of the abdomen between January 2018 and June 2019 were included. Results Nine patients underwent breast reconstruction with thirteen Sc-GAP makeover flaps, of which nine flaps were innervated. Indications were the abdomen not being available as a donor site ( n = 4) or the flank region was preferred as a donor site by the patient ( n = 5). The total operative time was 430 min on average (range 311–683). Mean flap weight was 638 g (range 370–1004) and the mean ischemia time was 53 ± 9.96 min. Coupler size used was 2.0–2.5 mm. All flaps survived. Conclusion The Sc-GAP makeover flap overcomes the disadvantages of the conventional gluteal flaps, especially by eliminating the need for position changes during the reconstruction procedure. It is a reliable flap that provides sufficient volume and good esthetic outcomes. Level of evidence: Level IV, therapeutic study.

Eye drops and ointments are the most prescribed methods for ocular drug delivery. However, due to low drug bioavailability, rapid drug elimination, and low patient compliance there is a need for improved ophthalmic drug delivery systems. This study provides insights into the design of a new drug delivery device that consists of an ocular coil filled with ketorolac loaded PMMA microspheres. Nine different ocular coils were created, ranging in wire diameter and coiled outer diameter. Based on its microsphere holding capacity and flexibility, one type of ocular coil was selected and used for further experiments. No escape of microspheres was observed after bending the ocular coil at curvature which reflect the in vivo situation in human upon positioning in the lower conjunctival sac. Shape behavior and tissue contact were investigated by computed tomography imaging after inserting the ocular coil in the lower conjunctival fornix of a human cadaver. Thanks to its high flexibility, the ocular coil bends along the circumference of the eye. Because of its location deep in the fornix, it appears unlikely that in vivo, the ocular coil will interfere with eye movements. In vitro drug release experiments demonstrate the potential of the ocular coil as sustained drug delivery device for the eye. We developed PMMA microspheres with a 26.5 +/- 0.3 wt% ketorolac encapsulation efficiency. After 28 days, 69.9% +/- 5.6% of the loaded ketorolac was released from the ocular coil when tested in an in vitro lacrimal system. In the first three days high released dose (48.7% +/- 5.4%) was observed, followed by a more gradually release of ketorolac. Hence, the ocular coil seems a promising carrier for ophthalmic drugs delivery in the early postoperative time period.

A histological study of a structure between the posterior horn of the lateral meniscus and the anterior cruciate ligament. Bilateral fresh-frozen cadaveric knees of two male donors (age 71 and 76 years) with no history of prior knee injury were examined. All dissections were performed by one experienced orthopaedic surgeon. Haematoxylin and Eosin staining was used to reveal tissue morphology. Goldner trichrome staining was used to evaluate the connective tissue. S100 and PGP 9.5 labelling were used for immunohistochemical analysis. In all cadaveric knees, a structure between the posterior horn of the lateral meniscus and the anterior cruciate ligament was identified. Histological analysis confirmed the ligamentous nature of this structure. Furthermore, Golgi tendon organs were observed within the ligamentous structure. This is the first study showing the presence of mechanoreceptors within the ligamentous structure between the posterior horn of the lateral meniscus and the anterior cruciate ligament. The ligamentous structure could contribute to stability of the knee by providing proprioceptive input, while preservation of the ligamentous structure might ensure a better functional outcome after surgery.

OBJECTIVEComplications after adult spinal deformity surgery are common, with implant-related complications occurring in up to 27.8% of cases. Sublaminar wire fixation strength is less affected by decreasing trabecular bone density in comparison to pedicle screw (PS) fixation due to the predominant cortical bone composition of the lamina. Sublaminar fixation may thus aid in decreasing implant-related complications. The goal of this study was to compare fixation characteristics of titanium sublaminar cables (SCs), ultra-high-molecular-weight polyethylene (UHMWPE) tape, PSs, and PSs augmented with UHMWPE tape in an ex vivo flexion-bending setup.METHODSThirty-six human cadaver vertebrae were stratified into 4 different fixation groups: UHMWPE sublaminar tape (ST), PS, metal SC, and PS augmented with ST (PS + ST). Individual vertebrae were embedded in resin, and a flexion-bending moment was applied that closely resembles the in vivo loading pattern at transitional levels of spinal instrumentation.RESULTSThe failure strength of PS + ST (4522 ± 2314 N) was significantly higher compared to the SC (2931 ± 751 N) and PS (2678 ± 827 N) groups, which had p values of 0.028 and 0.015, respectively (all values expressed as the mean ± SD). Construct stiffness was significantly higher for the PS groups compared to the stand-alone sublaminar wiring groups (p = 0.020). In contrast to SC, ST did not show any case of cortical breach.CONCLUSIONSThe higher failure strength of PS + ST compared to PS indicates that PS augmentation with ST may be an effective measure to reduce the incidence of screw pullout, even in osteoporotic vertebrae. Moreover, the lower stiffness of sublaminar fixation techniques and the absence of damage to the cortices in the ST group suggest that ST as a stand-alone fixation technique in adult spinal deformity surgery may also be clinically feasible and offer clinical benefits.

Background Patient satisfaction after breast reconstruction is dependent on both esthetics and functional outcomes. In an attempt to improve breast sensibility, a sensory nerve coaptation can be performed. The aim of this study was to objectify the sensory recovery in patients who, by chance, underwent bilateral autologous breast reconstruction with one innervated and one non-innervated flap. It must be emphasized that the intention was to coaptate the sensory nerves on both sides. Methods The cohort study was carried out in the Maastricht University Medical Center between August 2016 and August 2018. Patients were eligible if they underwent bilateral non-complex, autologous breast reconstruction with unilateral sensory nerve coaptation and underwent sensory measurements using Semmes–Weinstein monofilaments at 12 months of follow-up. Sensory outcomes were compared using t tests. Results A total of 15 patients were included, all contributing one innervated and one non-innervated flap. All patients had a follow-up of at least 12 months, but were measured at different follow-up points with a mean follow-up of 19 months. Sensory nerve coaptation was significantly associated with better sensation in the innervated breasts and showed better sensory recovery over time, compared to non-innervated breasts. Moreover, the protective sensation of the skin can be restored by sensory nerve coaptation. Conclusions The study demonstrated that sensory nerve coaptation leads to better sensation in the autologous reconstructed breast in patients who underwent bilateral breast reconstruction and, by chance, received unilateral sensory nerve coaptation.

INTRODUCTION:Better sensation in the reconstructed breast improves the quality of life. Sensory nerve coaptation is a valuable addition to autologous breast reconstruction. There are few publications concerning the sensory nerves of the breast and the nipple-areola complex and reports are contradictory, so it is unknown which nerve is best suited as a recipient for coaptation. The current study serves as a proof of concept. MATERIALS AND METHODS:The areas innervated by the anterior cutaneous branches (ACBs) of the intercostal nerves (ICNs) were studied on two separate occasions in two healthy women. First, the ACBs of ICNs 2-5 were individually blocked using ultrasound. Next, the ACBs of all levels were blocked simultaneously. Sensation was measured using Semmes-Weinstein monofilaments. The numbed areas corresponding to the ICNs were drawn in a raster of 2 × 2 cm. RESULTS:The largest area was supplied by the ACB of the 4th ICN, located in the upper (UIQ) and the lower (LIQ) inner quadrants of the breast. The 2nd-largest area was supplied by the ACB of the 3rd ICN. Blockage of ACBs 2-5 affected sensation in the nipple and the areola. CONCLUSIONS:Blockage of all levels 2-5 partially affected sensation in the nipple-areola complex, suggesting innervation by a nerve plexus consisting of both ACBs and lateral cutaneous branches (LCBs). ACB4 supplied the largest area of the breast in the UIQ and LIQ and could be best suited for sensory nerve coaptation to optimize sensation in the autologously reconstructed breast.

BackgroundDuring several anesthesiological procedures, needles are inserted through the skin of a patient to target nerves. In most cases, the needle traverses several tissues—skin, subcutaneous adipose tissue, muscles, nerves, and blood vessels—to reach the target nerve. A clear identification of the target nerve can improve the success of the nerve block and reduce the rate of complications. This may be accomplished with diffuse reflectance spectroscopy (DRS) which can provide a quantitative measure of the tissue composition. The goal of the current study was to further explore the morphological, biological, chemical, and optical characteristics of the tissues encountered during needle insertion to improve future DRS classification algorithms.MethodsTo compare characteristics of nerve tissue (sciatic nerve) and adipose tissues, the following techniques were used: histology, DRS, absorption spectrophotometry, high‐resolution magic‐angle spinning nuclear magnetic resonance (HR‐MAS NMR) spectroscopy, and solution 2D 13C‐1H heteronuclear single‐quantum coherence spectroscopy. Tissues from five human freshly frozen cadavers were examined.ResultsHistology clearly highlights a higher density of cellular nuclei, collagen, and cytoplasm in fascicular nerve tissue (IFAS). IFAS showed lower absorption of light around 1200 nm and 1750 nm, higher absorption around 1500 nm and 2000 nm, and a shift in the peak observed around 1000 nm. DRS measurements showed a higher water percentage and collagen concentration in IFAS and a lower fat percentage compared to all other tissues. The scattering parameter (b) was highest in IFAS. The HR‐MAS NMR data showed three extra chemical peak shifts in IFAS tissue.ConclusionCollagen, water, and cellular nuclei concentration are clearly different between nerve fascicular tissue and other adipose tissue and explain some of the differences observed in the optical absorption, DRS, and HR‐NMR spectra of these tissues. Some differences observed between fascicular nerve tissue and adipose tissues cannot yet be explained but may be helpful in improving the discriminatory capabilities of DRS in anesthesiology procedures. Lasers Surg. Med. 50:948–960, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Introduction: Autologous breast reconstruction has become the standard care for breast cancer patients. Although excellent cosmetic results can be achieved, most reconstructed breasts fail to regain normal sensation. Nerve coaptation of the flap has been suggested to improve sensation; the effect of the donor flap native sensory threshold on the degree of sensory restoration is yet to be determined. The aim of this study is to evaluate the differences in sensation between various potential donor site regions in comparison to the sensation of the healthy breast. Patients and methods: A cross-sectional study in healthy women was performed in the Maastricht University Medical Centre. Monofilaments were used to measure sensation in the breast and at different flap donor sites: deep inferior epigastric perforator (DIEP), lateral thigh perforator (LTP), profunda artery perforator (PAP), superior gluteal artery perforator (SGAP) and transverse musculocutaneous gracilis (TMG) flaps. The Wilcoxon signed rank test was used to analyse statistical significance in sensation. Results: Fifty women with a mean age of 49 +/- 2.72 years and mean BMI of 26.14 +/- 0.89 kg/m(2) were included in the study. The median monofilament value of the normal breasts was 2.97(2.56-3.55). The median monofilament value of each donor site and p value when compared to the healthy breast were as follows: DIEP flap, 2.62 (2.36-3.22) p < 0.01; LTP flap, 3.61 (2.83-4.08) p < 0.01; PAP flap, 3.09 (2.67-3.5) p = 0.97; SGAP flap, 3.22 (2.64-3.87) p = 0.01; and TMG flap, 3.03 (2.6-3.47) p = 0.69. Conclusions: There is a significant difference in sensation between the various donor site regions for breast reconstruction and the healthy breast. This may be taken into consideration for donor site selection. (C) 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

•Trajectory of nerves in the abdominal wall.•Anterior cutaneous nerve entrapment syndrome (ACNES).•Anatomy in respect to performing a neurectomy.

PURPOSE:Thoracic paravertebral block (TPVB) may be an alternative to thoracic epidural analgesia. A detailed knowledge of the anatomy of the TPV-space (TPVS), content and adnexa is essential in understanding the clinical consequences of TPVB. The exploration of the posterior TPVS accessibility in this study allows (1) determination of the anatomical boundaries, content and adnexa, (2) description of an ultrasound-guided spread of low and high viscous liquid.METHODS:In two formalin-fixed specimens, stratification of the several layers and the 3D-architecture of the TPVS were dissected, observed and photographed. In a third unembalmed specimen, ultrasound-guided posterolateral injections at several levels of the TPVS were performed with different fluids.RESULTS:TPVS communicated with all surrounding spaces including the segmental dorsal intercostal compartments (SDICs) and the prevertebral space. TPVS transitions to the SDICs were wide, whereas the SDICs showed narrowed transitions to the lateral intercostal spaces at the costal angle. Internal subdivision of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Caudally injected fluids spread posteriorly to the costodiaphragmatic recess, showing segmental intercostal and slight prevertebral spread.CONCLUSIONS:Our detailed anatomical study shows that TPVS is a potential space continuous with the SDICs. The separation of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Based on the ultrasound-guided liquid spread we conclude that the use of a more lateral approach might increase the probability of intravascular puncture or catheter position.