Background:. Prior studies have shown that intra-articular injection of autologous fat may be a viable, less invasive approach for the treatment of carpometacarpal (CMC) joint arthritis, compared with trapeziecetomy. Small joint arthroscopy has also been found to be a useful tool in evaluation and treatment of arthritis. The authors present a treatment for CMC arthritis combining a minimally invasive approach for arthroscopic debridement with autologous fat grafting and platelet-rich plasma (PRP) injection. Methods:. Patients with Eaton stage II–IV CMC osteoarthritis underwent arthroscopic debridement and injection of autologous fat and PRP into the joint. Pre- and postoperative pain scores, functional outcomes, radiographic improvement in joint subluxation, patient satisfaction, and complications were evaluated. Results:. Forty-eight thumb CMC joint arthroscopies with fat grafting and PRP were performed. No intraoperative or immediate postoperative complications were experienced. No patients required revision surgery. Average preoperative pain scores with activity improved from 8.9 ± 0.9 to 3.3 ± 2.2 (P < 0.0001) and at rest improved from 5.0 ± 2.5 to 1.0 ± 1.3 (P < 0.0001). M1M2 overlap was used to measure radiographic subsidence. This improved from 4.4 ± 2.8 mm preoperatively to 6.8 ± 2.3 mm postoperatively, reflecting a relative improvement of 70% (P < 0.0042). High patient satisfaction was noted. CONCLUSIONS:. Treatment of the CMC joint using arthroscopic technique combined with autologous fat and PRP is effective in treating pain and joint subluxation. Additional prospective studies are underway for comparison to traditional arthroplasty techniques and to evaluate this technique’s potential for other small joint pathology.

Upper-extremity mucormycosis is a rare, life-threatening fungal infection mainly affecting immunocompromised patients. We report a case of a 30-year-old woman with acute myelogenous leukemia who developed this infection during her hospital stay. The culprit was Mucorales, a subgroup of Zygomycetes species known for fast-progressing, highly lethal infections. She presented with fever, chills, and a lesion on her left forearm that worsened despite initial broad-spectrum antibiotics. A punch biopsy confirmed the diagnosis, leading to antifungal therapy with isavuconazonium sulfate and later amphotericin B, combined with surgery. Timely intervention is critical because delayed treatment can result in severe complications and death. Early suspicion, histology, microscopy, and fungal cultures are vital for accurate diagnosis. Treatment primarily involves amphotericin B, whereas adjunctive therapies such as topical amphotericin B and hyperbaric oxygen show promise. This case underscores the importance of prompt medical and surgical action, enhancing early detection of mucormycosis in immunocompromised patients.

Background:Scaphocapitate arthrodesis (SCA) is a described technique for chronic wrist pathology such as Kienbock disease and carpal instability. The technique aims to preserve motion, while maintaining carpal height, preserving the radioscaphoid articulation, and offloading the lunate. Limited case series evaluate the outcomes of this previously described technique. We aim to determine if the collective, updated literature on outcomes of SCA support its continued application by the wrist surgeon. Furthermore, we investigated if any technical variations offer an advantage in improving patient-reported outcomes after SCA.Methods:A literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles selected for critical review were examined for patient demographic data, functional outcomes, radiographic outcomes, and complications. A qualitative analysis was then performed to synthesize the available date.Results:A total of 18 unique articles published between 1991 and 2022 were identified, representing a total of 285 individual cases of SCA. Nonunion rate ranged 0%-22%. Preoperative visual analog scale pain scores ranged from 3.2 to 10, whereas postoperative visual analog scale pain scores ranged from 0 to 4. Patient-reported outcomes are reported by validated instruments, including the Disabilities of the Arm, Shoulder, and Hand, QuickDASH, Patient-rated Wrist Evaluation, and Mayo Wrist Score.Conclusions:SCA is a viable treatment option for patients with Kienbock disease. SCA offers reliable improvements in patient pain, grip strength, and patient-reported outcomes.

Background The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. Methods Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT+CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. Results Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 +/- 4.74%), while there was a significant relative volume reduction in group B (-13.39 +/- 8.55%) and an even greater reduction in group C (-14.56 +/- 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. Conclusion The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23–73) years and mean BMI was 22.3 (range 17.6–32.4) kg/m2. Mean follow-up was 14.8 (range 3–33) months. The median weight of the omentum was 161.7 g (range 81–852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22–1.38) and 1.97 (range 0.24–3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Secondary lymphedema is a common condition among cancer survivors, and treatment strategies to prevent or treat lymphedema are in high demand. The development of novel strategies to diagnose or treat lymphedema would benefit from a robust experimental animal model of secondary lymphedema. The purpose of this methods paper is to describe and summarize our experience in developing and characterizing a rat hindlimb model of lymphedema. Here we describe a protocol to induce secondary lymphedema that takes advantage of micro computed tomography imaging for limb volume measurements and visualization of lymph drainage with near infrared imaging. To demonstrate the utility of this preclinical model for studying the therapeutic benefit of novel devices, we apply this animal model to test the efficacy of a biomaterials-based implantable medical device.

Background: Scars after reduction mammaplasty are a leading cause of patient dissatisfaction postoperatively. Laser therapy has been reported to treat hypertrophic and keloid scars with benefits of reducing pain, itching, and improving appearance. However, literature reporting on its use in the breast reduction population remains scarce. Methods: Female patients > 18 years of age interested in scar treatment after breast reduction were identified at a single institution. Exclusion criteria included open wounds and patients < 1-month post-op. Study participants were treated with the Aerolase Neo Elite 1064 nm Nd:YAG laser (Aerolase Corp., Tarrytown, NY) for three treatments spaced four weeks apart with three passes per treatment session. To assess patient reported outcome measures, the Breast-Q Reduction module was administered before and at the conclusion of treatment. Clinical assessment of scars was performed at each time point by a plastic surgeon. T testing and multivariate regression analyses were performed when appropriate and a p < 0.05 was considered statistically significant. Results: Sixteen patients with an average age of 49.3 years and BMI 28.5 kg/m2 were included. Patients ranged from Fitzpatrick type II to V. After completion of laser treatment sessions, average Breast-Q scores improved overall (139.3±15.0 versus 144.9±11.9, p<0.001) and individually within each subsection. Patients noted an improvement in scar visibility (3.2±0.7 versus 3.9 ±0.7, p < 0.001). This subjective improvement was supported by improvement in rating of overall scar appearance by the plastic surgeon post-treatment (p<0.001). Notably, number of days from surgery, age, and BMI were not independent predictors of post-treatment Breast-Q scores on multivariate regression analysis. Conclusions: The use of the 1064 nm Nd:YAG laser is both safe and effective for scar treatment after breast reduction. Utilizing this laser technique postoperatively results in higher patient satisfaction and improved scar appearance.

ABSTRACT:Humanitarian mission trips have been organized by several residency programs and organizations to cater to surgical care in underdeveloped countries. While there is cross-talk on the existence of such opportunities, there is a paucity of guidance to residents on participation in such trips, their benefits, and the myriad of intangibles to consider while planning to pursue such opportunities. Through this article, the authors highlight the background and utility of humanitarian surgical missions and summarize the clinical and surgical experiences that these trips offer for residents choosing to embark on these altruistic journeys.

Introduction The omental fat–augmented free flap (O-FAFF) is a recently developed technique for autologous breast reconstruction. Our aim of the study is to evaluate the outcomes of our early case series. We assess the O-FAFF donor site morbidity in terms of postoperative pain, narcotic, and antiemetic use. Methods A retrospective analysis of patients undergoing O-FAFF from 2019 to 2021 was performed. Patients were evaluated for demographic data, operative time, hospital course, and complications. Mean pain scores (1–10 scale) and narcotic pain medication use in oral morphine equivalents and doses of antiemetic medications during their hospital course were analyzed. We compared outcomes of our O-FAFF group with those of a control group of patients who underwent breast reconstruction with traditional free abdominal tissue transfer. Results A total of 14 patients underwent O-FAFF breast reconstruction, representing 23 breasts. Patients had an average age of 48.5 years (±2.3 years) and body mass index of 22.6 kg/m2 (±1.09 kg/m2). Average follow-up was 232 days (±51 days). Average mastectomy weight was 245.6 g (±30.2 g) and average O-FAFF weight was 271 g (±31.7 g). Average pain scores on postoperative day 1 (POD1), POD2, and POD3 were 3.1 (±0.28), 2.8 (±0.21), and 2.1 (±0.35), respectively. The average narcotic use by patients in oral morphine equivalents on POD1, POD2, and POD3 are 24.3 (±5.5), 21.9 (±4.6), and 6.2 (±2.4), respectively. Total narcotic use during hospital stay was 79.4 mg (±11.1 mg). Average pain scores and narcotic use are significantly lower when compared with a previously published cohort of patients who underwent autologous breast reconstruction with free abdominal tissue transfer (P < 0.05). Average antiemetic use was lower in the O-FAFF group compared with the control group: 3.5 versus 4.8 doses (P = 0.6). Hospital length of stay was 3.0 days (±0.0 days). No complications were noted (0%). Patients were universally satisfied with their reconstructive outcome (100%). Conclusions The O-FAFF is proven to be a viable method of autologous breast reconstruction. Early series of patients undergoing O-FAFF reconstruction suggest a lower donor site morbidity as demonstrated by lower postoperative pain scores and lower consumptions of narcotic pain medications.

Background:. Autologous fat grafting is a commonly used technique in plastic surgery that can also be applied broadly in hand surgery. We present a case series to demonstrate the diverse indications for fat grafting in hand surgery. Methods:. We retrospectively reviewed cases of fat grafting in the upper extremity in 2020. Cases representing a unique application of fat grafting were identified. Patient data, including demographics, diagnoses, preoperative and postoperative assessments, complications, patient satisfaction, and surgical operative reports, were recorded. Results:. Five patients representing distinct indications for autologous fat grafting in the upper extremity were identified. Indications included hand rejuvenation (20.0%), burn/scar management (20.0%), tenolysis (20.0%), revision nerve decompression (20.0%), and carpometacarpal joint arthritis (20.0%). Average patient age was 60.4 years (range, 42–71). Average volume of fat injected was 15.2 ml (range, 1–37 ml). No major complications were noted (0.0%). All patients expressed satisfaction with their overall result with good functional outcomes (100%). Conclusions:. Autologous fat grafting can be applied broadly in hand surgery. Indications for fat grafting in hand surgery include hand rejuvenation, burn/scar management, tenolysis, revision nerve decompression, and thumb carpometacarpal arthritis. Hand surgeons can easily incorporate fat grafting into their daily practice. Current literature supports fat grafting as a viable technique in hand surgery with lower-level studies.

Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridgeTM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridgeTM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (−4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to −1.0% (−3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.

Background: We tested our hypothesis that implantation of aligned nanofibrillar collagen scaffolds (BioBridge (TM)) can both prevent and reduce established lymphedema in the rat lymphedema model. Our authors report clinical cases that demonstrate new lymphatic formation guided by BioBridge (TM) as seen by near-infrared (NIR) fluoroscopy and magnetic resonance (MR) lymphography. Methods: A rat lymphedema model was utilized. A prevention group received implantation of BioBridge (TM) immediately after lymphadenectomy. A lymphedema group received implantation of BioBridge (TM) with autologous adipose-derived stem cells (ADSC; treatment group) or remained untreated (control group). All subjects were observed for 4 months after lymphadenectomy. The hindlimb change was evaluated using computed tomography-based volumetric analysis. Lymphagiogenesis was assessed by indocyanine green (ICG) lymphography. Results: Animals in the treatment group showed a reduction in affected limb volume. Animals in the prevention group showed no increase in the affected limb volume. ICG fluoroscopy demonstrated lymph flow and formation of lymphatics toward healthy lymphatics. Conclusions: In the rat lymphedema model, implantation of BioBridge (TM) at the time of lymph node removal prevents the development of lymphedema. Treatment of established lymphedema with the BioBridge (TM) and ADSC reduces lymphedema. New lymphatic vessels are demonstrated by NIR fluoroscopy and MR lymphography. These findings have implications for the treatment of lymphedema in human subjects.

Autologous fat grafting is commonly used in plastic and reconstructive surgery, but its indications are less well known in the hand surgery literature. Autologous fat grafting is frequently used for its anti-inflammatory, proangiogenic, and regenerative properties, which can be useful in treating the hand and upper extremity. We present a summary of the current literature on autologous fat grafting in the hand and upper extremity and discuss the applications, outcomes, techniques, safety, and level of evidence.

Background: Nipple-sparing mastectomy is commonly performed when oncologically feasible. Although the nipple-areola complex (NAC) is preserved, patients are left with significantly altered nipple sensation after mastectomy. To optimize breast reconstruction outcomes, the NAC as well as its sensation should ideally be preserved. We investigate outcomes of NAC neurotization in patients undergoing mastectomy for both gender-affirmation and oncologic indications.

Background ReSurge International is a nongovernmental organization that organizes surgical team trips to low- and middle-income countries. Cleft palate repair is commonly performed on these trips. A comprehensive cleft care program was implemented to help reduce postoperative palatal fistula rates. Methods A retrospective review of all patients undergoing cleft palate repair surgery with ReSurge International in Vietnam from 2013 through 2019 was performed. The cleft care program was implemented in 2018. This intervention involved preoperative education of patients and close postoperative monitoring. Critically, this program also provided closer access to providers. Subsequent follow-up was performed by a ReSurge physician. Parent-reported outcomes were assessed preoperatively and postoperatively using 5-point Likert-like survey questions. Results Two hundred three patients underwent cleft palate repair. The patients were older and of higher Veau classification than is usually seen in the United States. The palatal fistula rate in the preintervention group was 37.5% and 14.3% in the intervention group (P = 0.014). Patients without fistulas demonstrated improvements on parent-reported outcomes compared with those with fistulas, with food less likely to go up their nose (P < 0.001), less difficulty eating (P < 0.001), and more understandable speech (P = 0.015). Conclusions Implementation of a comprehensive cleft palate program reduced postoperative fistula rates by more than 50%. Improvements in parent-reported outcomes were observed after surgery among patients without fistulas. The blueprint for improved outcomes in these more complex patients includes enhanced perioperative patient counseling, close follow-up, and maintenance of communication with patients.

Background: In contrast to cosmetic abdominoplasty, abdominal flap harvest can result a high degree of morbidity to the abdominal wall. Poor abdominal wall aesthetics that can result following free flap harvest including a high abdominal incision and post-operative hernia or bulge. We report our experience in optimizing cosmesis of the abdominal donor site with the use of a low incision, fascial plication and routine mesh reinforcement. Methods: A retrospective chart review of patients who underwent breast reconstruction with free abdominal tissue transfer from 2013-2017. Pedicled flaps and superior inferior epigastric artery flaps were excluded. Patient demographics, oncologic history, ablative and reconstructive surgery details focusing on abdominal closure techniques, and postoperative complications were evaluated. Results: 135 patients were identified who underwent 223 abdominal free flaps. 59 (26.5%) DIEP flaps were harvested, while 160 (71.7%) msTRAM and 4 (1.8%) fTRAM flaps were harvested (p<0.0001). 160 (71.7%) donor sites closures utilized polypropylene mesh, 9 (4.0%) were closed with biologic mesh and 3 (1.3%) closures used no mesh (p<0.0001). No hernias were observed (0%), while 6 abdominal bulges were identified (2.7%). There were no differences in the rates of abdominal bulge after donor site closure in the DIEP compared with msTRAM and fTRAM groups (3.4% vs 2.4%, p=0.7). No patients required mesh explantation during the study follow up period. Conclusion: To parallel cosmetic abdominoplasty, our authors advocate for a low incision, fascial plication and routine mesh reinforcement of the abdominal wall following free flap harvest.

BACKGROUND:Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage.METHODS:We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure.RESULTS:Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group.CONCLUSIONS:Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

We determined the aesthetic outcomes of autologous breast reconstruction in comparison to cosmetically altered or natural breasts. We also examined the effect of perceptions on aesthetic outcomes of breast reconstruction. Images of 10 patients (autologous breast reconstruction following bilateral nipple sparing mastectomy (NSM) (n=5), bilateral breast reduction (n=1), bilateral mastopexy (n=1), bilateral augmentation (n=1), unoperated natural breasts (n=2)), were compiled into a blind three-part survey. Part one asked participants to determine whether the presented breasts are reconstructed after mastectomy and measure aesthetic outcomes (1=poor and 4=excellent). Part two ranks breasts from most desirable to least desirable. Part three presents side-by-side unlabeled pre and postoperative images of patients who have undergone autologous breast reconstruction and asks to select the more aesthetically pleasing breasts. Two thousand images were quantified from 100 surveys (83.3% response rate). Age range of participants was 18-80. Response was not statistically different based on demographics. The rate of correctly identifying breasts as reconstruction after NSM was 62.8% and as natural was 64%. Mean aesthetic scores between the reconstructed and natural breasts were equivalent. Breasts perceived as reconstruction scored significantly lower in five aesthetic factors. The top 3 most desired breasts were augmentation, reconstruction after NSM, and unoperated natural breasts. In paired pre- and postoperative photo comparison, all responses favored postoperative breasts. Aesthetic outcomes after autologous breast reconstruction can be equivalent to natural breasts. Breasts perceived as reconstruction are ranked poorer in aesthetic factors compared to those perceived as natural breasts.

: Breast reconstruction after mastectomy is increasingly being performed for women diagnosed with breast cancer, as well as those with a genetic predisposition to developing breast cancer. Techniques include implant-based or autologous tissue reconstruction where the abdominal soft tissue is most commonly used. As more women seek to avoid the use of implants, minimize donor site morbidity, and desire a natural-appearing breast after reconstruction, an alternative to the standard approaches is needed. The omentum has historically been used as a pedicled flap for surgical defects or infection. It has been used for breast reconstruction, but primarily as a pedicled flap and for treatment of partial breast defects. To optimize the use of the omentum for breast reconstruction, a novel technique using an omental fat-augmented free flap (O-FAFF) has recently been reported. This approach allows 360 degrees of freedom in positioning the autologous tissue reconstruction while also increasing the volume of the autologous free flap using fat grafting. An acellular dermal matrix (ADM) mold is used to provide structure. The result is an augmented appearance that feels similar to biologic soft tissue. This review discusses the evolution of breast reconstruction using the omentum and the potential increasing role that the O-FAFF may have in breast reconstruction.