Postparetic Synkinesis: Objective and Subjective Comparisons of Depressor Anguli Oris Myectomies versus Depressor Anguli Oris and Buccinator Myectomies

BACKGROUND

 Muscles affected by postparetic synkinesis have imbalanced tonicity that limit perioral mimetic movement and inhibit the ability to smile. The depressor anguli oris (DAO) muscle has been a common myectomy target for the treatment of perioral synkinesis. While addition of buccinator myectomies to DAO myectomies has risen, no studies have analyzed the effects of buccinator myectomies. The goal of this study was to evaluate and compare the effects of a DAO myectomy with and without concomitant buccinator myectomy through objective facial metrics and subjective patient-reported outcomes.

METHODS

 This study is a retrospective review of patients with postparetic synkinesis who underwent DAO myectomy (DAO myectomy group) or DAO myectomy with buccinator myectomy (DAO + Buccinator myectomies group). Outcomes included postoperative differences in objective smile measures (smile angle, excursion, and dental show) using validated software and patient-reported outcomes using the Facial Disability Index (FDI) questionnaire and a myectomy-specific questionnaire.

RESULTS

 After chart review, 18 patients were included in the DAO myectomy group and 19 in the DAO + Buccinator myectomies group. There were no significant postoperative differences between the groups in (1) smile excursion, angle, or dental show at resting, closed smile, or open smile (p > 0.05), (2) FDI physical and social scores, p = 0.198 and 0.932, respectively, or (3) myectomy-specific questionnaire responses (p > 0.05).

CONCLUSION

 The addition of a buccinator myectomy to a DAO myectomy does not provide significant clinical benefit when compared with an isolated DAO myectomy, based on objective measures and subjective patient-reported outcomes.

Polyetheretherketone Implant Cranioplasty for Large Cranial Defects: A Seven-Year Follow-Up

BACKGROUND

Goals of a cranioplasty include protection of the brain, restoration of normal appearance, and neurological function improvement. Although choice of materials for cranial remodeling has changed through the years, computer-designed polyetheretherketone (PEEK) implant has gained traction as a preferred material used for cranioplasty. However, long-term outcomes and complications of PEEK implants remain limited. The goal of this study was to report long-term clinical outcomes after PEEK implant cranioplasty.

METHODS

A retrospective chart review was performed on patients undergoing PEEK cranioplasty between January 2007 and February 2023. Preoperative, intraoperative, and postoperative data were collected and analyzed.

RESULTS

Twenty-two patients were included in this study. Mean postoperative follow-up time was 83.45 months (range: 35.47-173.87). Before PEEK implant cranioplasty, patients with multiple cranial procedures had undergone a mean of 2.95 procedures. PEEK implant cranioplasty indications were prior implant infection (14) and secondary reconstruction of cranial defect (8). The mean implant size was 180.43 cm2 (range: 68.00-333.06). Four patients received a 2-piece implant. Postoperative complications included: perioperative subgaleal self-resolving fluid collection in 1 patient, hematoma in another, and 3 infections resulting in explantations with successful reinsertion in 2 patients. Four of 5 patients with preoperative history of seizures reported improved seizures and all 4 patients with preoperative syndrome of the trephined reported improved symptoms and neurological function.

CONCLUSION

At a mean follow-up of 7 years, most PEEK implants continued to provide protection to the brain and consistent symptom relief in patients suffering from prior postcraniectomy/craniotomy sequelae of seizures and syndrome of the trephined.

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures

BACKGROUND

 In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs.

METHODS

 Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry.

RESULTS

 Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05).

CONCLUSION

 Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.

Effect of Lower Extremity Nerve Decompression in Patients with Painful Diabetic Peripheral Neuropathy: The DNND Randomized, Observation Group- and Placebo Surgery-controlled Clinical Trial

OBJECTIVE

Evaluate the effect of nerve decompression on pain in patients with lower extremity painful Diabetic Peripheral Neuropathy (DPN).

SUMMARY BACKGROUND DATA

Currently, no treatment provides lasting relief for patients with DPN. Benefits of nerve decompression remain inconclusive.

METHODS

This double-blinded, observation- and same-patient sham surgery-controlled randomized trial enrolled patients aged 18-80 years with lower extremity painful DPN who failed one-year of medical treatment. Patients were randomized to nerve decompression- or observation-group (2:1). Decompression-group patients were further randomized and blinded to nerve decompression in either right or left leg and sham surgery in the opposite leg. Pain (11-point Likert score) was compared between decompression and observation groups and between decompressed versus sham legs at 12 and 56 months.

RESULTS

Of 2987 screened patients, 78 were randomized. At 12 months, compared with controls (n=37), both right-decompression-group (n=22) and left-decompression-group (n=18) reported lower pain (mean difference for both, -4.46; [95% CI, -6.34 to -2.58 and -6.48 to -2.45 respectively]; P<0.0001). Decompressed and sham legs equally improved. At 56 months, compared with controls (n=14), pain was lower in both the right-decompression-group (n=20) (mean difference, -7.65; [95% CI, -9.87 to -5.44]; P<0.0001) and left-decompression-group (n=16) (mean difference, -7.26; [95% CI, -9.60 to -4.91]; P<0.0001). Mean pain score was lower in decompressed versus sham legs (mean difference, 1.57 [95% CI, 0.46 to 2.67]; P=0.0002).

CONCLUSION

Although nerve decompression was associated with reduced pain, the benefit of surgical decompression needs further investigation since a placebo effect may be responsible for part or all of these effects.

Neurofibromatosis Type II and Facial Paralysis: Clinical Evaluation and Management

BACKGROUND

Facial paralysis secondary to neurofibromatosis type 2 (NF2) presents the reconstructive surgeon with unique challenges because of its pathognomonic feature of bilateral acoustic neuromas, involvement of multiple cranial nerves, use of antineoplastic agents, and management. Facial reanimation literature on managing this patient population is scant.

METHODS

A comprehensive literature review was performed. All patients with NF2-related facial paralysis who presented in the past 13 years were reviewed retrospectively for type and degree of paralysis, NF2 sequelae, number of cranial nerves involved, interventional modalities, and surgical notes.

RESULTS

Twelve patients with NF2-related facial paralysis were identified. All patients presented after resection of vestibular schwannoma. Mean duration of weakness before surgical intervention was 8 months. On presentation, one patient had bilateral facial weakness, 11 had multiple cranial nerve involvement, and seven were treated with antineoplastic agents. Two patients underwent gracilis free functional muscle transfer, five underwent masseteric-to-facial nerve transfer (of whom two were dually innervated with a crossfacial nerve graft), and one patient underwent depressor anguli oris myectomy. Trigeminal schwannomas did not affect reconstructive outcomes if trigeminal nerve motor function on clinical examination was normal. In addition, antineoplastic agents such as bevacizumab and temsirolimus did not affect outcomes if stopped in the perioperative period.

CONCLUSIONS

Effectively managing patients with NF2-related facial paralysis necessitates understanding the progressive and systemic nature of the disease, bilateral facial nerve and multiple cranial nerve involvement, and common antineoplastic treatments. Neither antineoplastic agents nor trigeminal nerve schwannomas associated with normal examination affected outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Lateral Tarsal Strip versus Tensor Fascia Lata Sling for Paralytic Ectropion: Comparison and Long-Term Outcomes

BACKGROUND

Paralytic ectropion increases risk for corneal injury in facial palsy patients. Although a lateral tarsal strip (LTS) provides corneal coverage through superolateral lower eyelid pull, the unopposed lateral force may result in lateral displacement of the lower eyelid punctum and overall worsening asymmetry. A tensor fascia lata (TFL) lower eyelid sling may overcome some of these limitations. This study quantitatively compares scleral show, punctum deviation, lower marginal reflex distance, and periorbital symmetry between the two techniques.

METHODS

Retrospective review was performed on facial paralysis patients who underwent LTS or TFL sling surgery with no prior lower lid suspension procedures. Standardized preoperative and postoperative images in primary gaze position were used to measure scleral show and lower punctum deviation using ImageJ, and lower marginal reflex distance using Emotrics.

RESULTS

Of 449 facial paralysis patients, 79 met inclusion criteria. Fifty-seven underwent LTS surgery and 22 underwent TFL sling surgery. Compared with preoperatively, lower medial scleral show improved significantly with both LTS (10.9 mm 2 ; P < 0.01) and TFL (14.7 mm 2 ; P < 0.01). The LTS group showed significant worsening of horizontal and vertical lower punctum deviation when compared with the TFL group (both P < 0.01). The LTS group was unable to achieve periorbital symmetry between the healthy and paralytic eye across all parameters measured postoperatively ( P < 0.01); and the TFL group achieved symmetry in medial scleral show, lateral scleral show, and lower punctum deviation.

CONCLUSION

In patients with paralytic ectropion, TFL sling provides similar outcomes to LTS, with the added advantages of symmetry without lateralization or caudalization of the lower medial punctum.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Optimizing Facial Function in Patients With High-Risk Recurrent Pleomorphic Adenoma and a History of Facial Nerve Injury

BACKGROUND

Parotid pleomorphic adenoma (PA) patients present significant diagnostic and surgical challenges rendering them high risk for facial nerve injury. Recurrent PA patients often present with history of facial nerve injury or previous reanimations making salvage of the facial nerve or previous reanimations significantly more complex. The study aim is to share our experience with this high risk for facial nerve injury population and review the literature.

METHODS

Adult patients with recurrent PA and history of facial nerve injury with at least 3 months of follow-up were analyzed for demographics, facial palsy history, previous head and neck surgeries, previous facial paralysis reconstruction, preoperative imaging, surgical approach, and postoperative outcomes.

RESULTS

Four female patients were identified with an average age of 62 years. All patients underwent an initial protective dissection of the facial nerve or previous reanimation reconstruction by the facial nerve reconstructive team followed by the extirpative team. The average number of previous head and neck surgeries was 5, the number of recurrences was 2, and follow-up was 20 months. Half had prior dynamic facial reanimation. Two patients underwent complete preextirpative dissection of the facial nerve resulting in neuropraxia, which recovered completely after an average of 143 days. A third patient presented with 2 recurrences, both during and after reanimation with a dually innervated free functional muscle transfer. The reconstruction was salvaged, and motion was achieved. A fourth patient presented with benign preoperative findings, but intraoperative findings confirmed malignancy, necessitating facial nerve sacrifice, followed by immediate intratemporal grafting of the facial nerve and masseteric nerve transfer. Motion appeared 139 days postoperatively.

CONCLUSIONS

A multidisciplinary effort should be implemented in this high risk for facial nerve injury population with the primary goal of protecting the facial nerve or any previous reanimation procedures, yet with preparedness to apply any reconstructive strategy based on intraoperative findings.

Selective Myectomies Alone vs Selective Myectomies Combined with Selective Neurectomies in Patients with Post-paretic Synkinesis - Comparing Outcomes

BACKGROUND

In post-paretic synkinesis, muscle tone imbalance between upper and lower lip depressors and elevators, results in the inability to produce an effective smile. Surgical treatments to improve smile, focus on restoring tonicity balance between peri-oral muscles by weakening hyper-toned muscles through selective myectomies or selective neurectomies. The goal of this study was to compare objective outcomes between selective myectomies alone with those of selective myectomies combined with selective neurectomies.

METHODS

Retrospective cohort study performed on post-paretic synkinesis patients who underwent depressor anguli oris (DAO) myectomies or DAO and platysma myectomies with selective neurectomies. Objective outcomes included pre- and post-operative analyses of smile measures (excursion, angle, and dental show) and Botox administration (periorbital and platysmal).

RESULTS

Thirty-seven pa tients underwent DAO myectomies only (myectomy group) and eighteen patients underwent DAO and platysma myectomies with selective neurectomies (myectomy-neurectomy group). Within group analyses showed significant angle improvement in both groups (p<.05) and improved smile excursion in the myectomy-neurectomy group (p<.05). Between group comparisons showed significant closed mouth smile excursion improvement (difference in means: -1.14 millimeters; 95% CI -2.19 to -0.09; p=.034) and significant decrease in platysmal Botox administration (difference in means: 27.36 Botox units ; 95% CI 18.72 to 36.00; p<.001) in the myectomy-neurectomy group compared to the myectomy group.

CONCLUSIONS

This study suggests that selective myectomies and selective myectomies with selective neurectomies provide overlapping and differing benefits to peri-oral synkinesis. Selective neurectomies and platysma myectomy provided slightly improved excursion and significantly decreased botulinum injections to the platysma.

Dual Versus Single Innervation of Gracilis Free Functional Muscle Transfer in Facial Paralysis - Long-Term Resting and Dynamic Outcomes

BACKGROUND

Comparing long-term tone and excursion between single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis.

METHODS

Longstanding facial palsy patients treated with a FFMT innervated either by a nerve-to-masseter (single-innervation group) or by nerve-to-masseter and cross-facial-nerve graft (dual-innervation group) were included. One year minimal follow up was required. Outcome measures, based on standardized photos, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open teeth smile preoperatively, and at 3-months, 1-year, and 3-years postoperatively. Emotrics software (Massachusetts Eye and Ear Infirmary, Boston, MA) and ImageJ (Rasband, W.S., ImageJ, U.S, National Institutes of Health, Bethesda, MD) were used for measurements. Between group and within group longitudinal comparisons were analyzed.

RESULTS

At three years (single=24, dual=13), significance was found between groups in commissure position (single=26.42mm, dual=31.51mm, p<0.0001) and excursion with open mouth smile (single=31.32mm, dual=26.59mm, p<0.001). Single-innervation FFMT within group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, while dual-innervation group revealed significant improvements (3.67mm and p<0.001, 3.17mm and p<0.001 respectively). Teeth exposure revealed an increase in the dual-innervation group (single=35.753 mm 2, dual=64.177 mm 2), albeit significance was not observed.

CONCLUSIONS

Dually innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single innervated FFMT.

Cross Facial Nerve Grafting for Smile Restoration: Thoughts on Improving Graft Inset

Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional "babysitting" approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.

Use of Groin Neurectomies for Noniatrogenic Testicular and Groin Pain

Background Chronic groin neuralgia is a life-debilitating condition that plagues patients worldwide. While groin neuralgia is usually traced to iatrogenic causes (inguinal hernia repairs, vasectomy, and hysterectomy), there is a unique subset of patients that present with noniatrogenic groin neuralgia. The diagnosis and treatment of these patients present a particular challenge.

Methods A total of 30 patients (current mean age, 46.5 [range: 19–72] years) who presented with noniatrogenic groin neuralgia and received neurectomies on the iliohypogastric, ilioinguinal, and genitofemoral nerves between 2008 and 2017 were identified. A retrospective review of preoperative and immediate postoperative pain scores was compared with prospectively collected current pain on a Likert's scale (0–10). Additionally, patients were asked to complete a Short Form (SF)-20 and identify current pain medications. A two-sided Wilcoxon–Mann–Whitney test was used to analyze the data.

Results Of the 30 patients identified, 16 could participate (mean follow-up = 61 months). The average pain reduction for the entire group was 62.7%. When using an established 30% reduction pain as a marker for clinical significance, 12 successful and 4 unsuccessful patients had an average reduction of 81.1 and 7.68%, respectively (success rate of 75%). Patients with successful group showed a statistically significant increased social functioning (p = 0.012) and near-significant increase in mental health (p = 0.063). Improvements, albeit nonsignificant, in mean scaled scores for every other SF-20 quality of life (QoL) category were observed when comparing both groups.

Conclusion Neurectomy is a potentially beneficial surgery that can assuage pain and improve quality of life for patients with noniatrogenic groin neuralgia.

Depressor Anguli Oris Myectomy versus Transfer to Depressor Labii Inferioris for Facial Symmetry in Synkinetic Facial Paralysis

BACKGROUND

 Postparalytic synkinesis presents with a combination of hypo- and hypertonic muscles, leading to facial asynchrony with animation and at rest. One ubiquitous finding is a hypertonic depressor anguli oris (DAO) muscle and a weak depressor labii inferioris (DLI) muscle. The goal of this study was to evaluate the utility of DAO myectomy with or without its transfer to the weakened DLI in improving critical components of the dynamic smile.

METHODS

 From 2018 to 2020, this single-center, prospective study included of postparetic facial synkinetic patients with evidence of DAO hypertonicity who underwent DAO myectomy with or without transfer to DLI. Objective facial measurements were used to compare the effectiveness of DAO to DLI transfer to pure DAO myectomy in improving asymmetry of the synkinetic hemiface.

RESULTS

 Twenty-one patients with unilateral postparetic facial synkinesis with DAO hypertonicity were included; 11 underwent DAO myectomy, while 10 underwent DAO to DLI transfer. Baseline demographics and facial measurements were similar between the groups. DAO myectomy resulted in increased modiolus resting position, closed-mouth smile modiolus angle and excursion, open-mouth smile modiolus angle, excursion, dental show, and decreased lower lip height deviation. DAO to DLI transfer demonstrated similar findings but lacked significant increase in excursion and resulted in worsened lower lip height deviation.

CONCLUSION

 These findings illustrate the utility of DAO myectomy in improving imbalance in the synkinetic patient and necessitate further technical refinements for DAO transfers or a different approach for improving lower lip depression in this subgroup of patients.

Early Masseter to Facial Nerve Transfer May Improve Smile Excursion in Facial Paralysis

Supplemental Digital Content is available in the text.

Background:

Masseter-to-facial nerve transfer has been shown to be an effective and safe treatment option in patients with acute and subacute facial palsy. The present article aims to characterize whether there is a benefit in early nerve transfers while minimizing other confounding variables; we present a study that consist of only patients with complete facial nerve paralysis resulting from intratemporal facial nerve resections.

Methods:

Between 2012 and 2016, 7 masseter-to-facial nerve transfers were performed for complete facial nerve palsy after intratemporal proximal nerve resections. Pre- and postoperative photographic and video evaluations were performed using both the Sunnybrook facial grading scale and the MEEI FACE-gram software for more objective metric measurements. Statistical analysis was performed to determine which patient and surgical variables had significant effects on outcome.

Results:

Mean 14-month follow-up revealed that patients who underwent nerve transfer prior to 6 months’ denervation achieved postoperative oral commissural excursion of 11.1 mm versus 6.5 mm in patients who underwent nerve transfer after 6 months (P = 0.003). Performing masseter-to-facial nerve transfer to the main facial nerve trunk resulted in a significantly higher improvement in the modiolus-philtral ratio (31.6% versus 6.1%) than selective transfer in patients (P = 0.01) at the latest follow-up.

Conclusions:

Early masseter-to-facial nerve transfers, before 6 months of palsy duration, can potentially improve smile excursion and symmetry of open mouth smile. Additionally, truncal coaptations may provide improved tone over coapting to selective facial nerve branches. These findings necessitate larger studies regarding the importance of denervation time with fifth-to-seventh nerve transfers.

Sensation of the autologous reconstructed breast improves quality of life: a pilot study

Purpose

The number of breast cancer survivors continues to grow. Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. Impaired sensation remains a debilitating side effect with a significant impact on the quality of life. Microsurgical nerve coaptation of a sensory nerve has the potential to improve sensation of the reconstructed breast. This study investigates the effect of improved sensation of the reconstructed breast on the quality of life in breast cancer survivors.

Methods

A retrospective cohort study was performed in the Maastricht University Medical Center. Patients undergoing a DIEP flap breast reconstruction between January 2015 and January 2016 were included. The primary outcome was quality of life (BREAST-Q domain ‘physical well-being of the chest’). The Semmes–Weinstein monofilaments were used for objective sensation measurement of the reconstructed breast(s).

Results

Eighteen patients with and 14 patients without nerve coaptation responded. Nipple reconstruction was the only characteristic that differed statistically significant between both groups (p = 0.04). The BREAST-Q score for the domain physical well-being of the chest was 77.89 ± 18.89 on average in patients with nerve coaptation and 66.21 ± 18.26 in patients without nerve coaptation (p = 0.09). Linear regression showed a statistically significant relation between objectively measured sensation and BREAST-Q score for the domain physical well-being of the chest with a regression coefficient of − 13.17 ± 3.61 (p < 0.01).

Conclusions

Improved sensation in the autologous reconstructed breast, with the addition of microsurgical nerve coaptation, has a statistical significant positive impact on the quality of life in breast cancer survivors according to the BREAST-Q.

Case report: full-thickness forehead burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit

OBJECTIVE

This study aims to contextualize an unintended intraoperative electrocautery burn that occurred on our service within the spectrum of all intraoperative electrocautery burns.

METHODS

A case report of the incident was drafted, and the relevant literature present in PubMed and industry publications was reviewed.

RESULTS

Intraoperative electrocautery burns can be divided into 4 categories: (1) direct contact burns resulting from inappropriate operator use of the active electrode, (2) burns at the grounding electrode site due to improper attachment or placement, (3) burns resulting from electrode heating of pooled solutions, and (4) burns occurring outside the operative field as a result of circuits generated between the active electrode and an alternate grounding source. We herein report an unintended intraoperative electrocautery burn of the fourth category. An aberrant intraoperative circuit utilized previously placed in-dwelling titanium plating in the patient's right brow as the grounding electrode, resulting in 3 x 3-cm full-thickness skin necrosis overlying the site of hardware implantation.

CONCLUSIONS

Literature recommendations to reduce this type of electrocautery burn suggest avoiding grounding pad placement on the forearm and lateral thigh, although further investigation is needed to determine optimal grounding electrode placement with respect to known indwelling hardware.

The Two-Dermal-Flap Umbilical Transposition: A Natural and Aesthetic Umbilicus after Abdominoplasty

BACKGROUND

The aesthetic and natural appearance of the transposed umbilicus after abdominoplasty is a key factor to the overall result and satisfaction of patient and surgeon alike. In this article, the authors present a technique in umbilical transposition that creates a natural-appearing umbilicus.

METHODS

The skin in the neoumbilical position is deepithelialized and incised in the midline, thus creating two dermal flaps that are sutured down to the abdominal fascia, thereby creating a natural periumbilical concavity, inconspicuous scars, and a tension-free closure, resulting in a decreased chance for cicatricial umbilical scarring. Twenty patients underwent umbilical transposition during abdominoplasty with this technique between 2003 and 2005.

RESULTS

Both patient and surgeon satisfaction were very high, with three senior surgeons changing their surgical technique after being introduced to that described in this article. One complication culminated in partial skin dehiscence early in our experience when deep dermal sutures were not used for skin closure.

CONCLUSION

The technique described is simple, safe, and easily learned, and results in a very satisfying aesthetic and natural-appearing umbilicus in patients after abdominoplasty.

Two cases of pseudoaneurysm of the renal artery following laparoscopic partial nephrectomy for renal cell carcinoma: CT angiographic evaluation

Partial nephrectomy via a laparoscopic approach can be technically challenging, and associated vascular complications such as pseudoaneurysm may occur. CT with CT angiography is ideal for the noninvasive imaging of this process. This article reports two cases of pseudoaneurysm of the renal artery detected on CT as a complication of laparoscopic partial nephrectomy and demonstrates the usefulness of 3-D CT angiography in the evaluation of vascular pathology.

Management strategies for pyoderma gangrenosum: case studies and review of literature

Pyoderma gangrenosum (PG) is a systemic disease with cutaneous manifestations consisting of necrotizing ulceration. The etiology of PG is controversial, and optimal management strategies have not been established. Current management is primarily medical to control the systemic inflammatory process, with occasional surgical intervention at the ulcer site. Based on the current literature and on the authors' clinical experience, the optimal outcome depends on early diagnoses and a combination of medical and surgical therapy. Initial management is directed toward medical control of the inflammatory process and local wound care. Surgical strategies involve recipient site preparation via local wound care and serial allograft followed by autologous skin graft or muscle flap coverage when necessary. Long-term wound stabilization is obtained only through control of the systemic and local inflammatory process.

Giant plexiform neurofibroma of the back

Complete excision of a giant neurofibroma can be technically difficult. Thorough preoperative planning with magnetic resonance imaging, computed tomography, and arteriography are indicated to define the extent of the mass and to facilitate operative planning. By following the treatment guidelines discussed in this case report, the authors feel that these tumors can be excised safely with minimal morbidity.