David E. Kurlander

An anatomical study of the lesser occipital nerve and its potential compression points: implications for surgical treatment of migraine headaches.

Background: This study maps the course of the lesser occipital nerve and its potential compression sites in the posterior scalp. Methods: Twenty sides of 10 fresh cadaveric heads were dissected. Two fixed anatomical landmarks were used: the y axis was the vertical midline in the posterior scalp through the midline of the cervical spine. The x axis was a horizontal line drawn between the most anterosuperior points of the external auditory meatus. A topographic map of the lesser occipital nerve and its potential compression points was created. Results: The lesser occipital nerve emerged from the posterior border of the sternocleidomastoid muscle at an average of 6.4 ± 1.4 cm lateral to the y axis and 7.5 ± 0.9 cm caudal to the x axis. Branches of the occipital artery were found to interact with the lesser occipital nerve in 11 of the 20 hemiheads (55 percent). The mean location of the artery-nerve interaction was 5.1 ± 0.9 cm lateral to the y axis and 2 ± 1.45 cm caudal to the x axis. Two patterns of artery-nerve interaction were seen: a single site of artery crossing over the nerve in nine of 20 hemiheads (45 percent) and a helical intertwining relationship in two of 20 of hemiheads (10 percent). A fascial band was identified to compress the lesser occipital nerve in four of 20 hemiheads (20 percent). Conclusion: This anatomical study traced the lesser occipital nerve as it courses through the posterior scalp and mapped its potential decompression sites.

Patterns of cancer screening in primary care from 2005 to 2010.

Cancer screening recommendations vary widely, especially for breast, prostate, and skin cancer screening. Guidelines are provided by the American Cancer Society, the US Preventive Services Task Force, and various professional organizations. The recommendations often differ with regard to age and frequency of screening. The objective of this study was to determine actual rates of screening in the primary care setting.

Incidence and Survival of Primary Dermatofibrosarcoma Protuberans in the United States.

BACKGROUND Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma for which data on risk factors, incidence, and survival are limited. OBJECTIVE The authors sought to establish a comprehensive report on the incidence of and survival from primary DFSP. METHODS The authors used data from the 18 registries of the Surveillance, Epidemiology, and End Results Program from 2000 to 2010. RESULTS Overall incidence was 4.1 per million person-years and steady over the decade. Trunk was the most common anatomic site except in older men. Incidence among women was 1.14 times higher than men (95% confidence interval [CI] of rate ratio: 1.07–1.22). Incidence among blacks was almost 2 times the rate among whites (95% CI of rate ratio: 1.8–2.1). Ten-year relative survival of DFSP was 99.1% (95% CI: 97.6–99.7). Increased age, male sex, black race, and anatomic location of the limbs and head as compared with the trunk were associated with higher all-cause mortality. CONCLUSION This is the largest population-based study of DFSP derived from a cohort of almost 7,000 patients. The epidemiologic profile of DFSP differs from most skin cancers. Incidence is stable and highest among women and blacks. Worse survival is associated with increased age, male sex, black race, and anatomic location of the limbs and head.

In-depth review of symptoms, triggers, and treatment of temporal migraine headaches (Site II).

Background: This study was designed to report the details of the technique and assess the efficacy of surgical deactivation of temporal-triggered migraine headaches. It also examined the effect of surgical deactivation of temporal-triggered migraine headaches on migraine triggers and associated symptoms besides the pain. Methods: The authors analyzed the charts of 246 patients receiving surgery for temporal-triggered migraine headaches by a single surgeon (B.G.) over a 10-year period, who were followed for at least 1 year. Median regression adjusted for age, sex, and follow-up time was used to determine postoperative reduction in temporal-specific migraine headache index, which is the product of frequency, severity, and duration. The association between individual symptom or trigger resolution and index value reduction was studied by logistic regression. Details of the surgical treatment are discussed. Results: Eighty-five percent of patients reported a successful surgery (≥50 percent improvement of headache index) at least 12 months after surgery (mean follow-up, 3 years). Fifty-five percent reported complete elimination of temporal migraine headache. Symptoms resolving with successful site II surgery included nausea, photophobia, phonophobia, difficulty concentrating, vomiting, blurry vision, and eyelid ptosis (p < 0.05). Triggers resolving included letdown after stress, air travel, missed meals, bright lights, loud noises, fatigue, weather change, and certain smells (p < 0.05). Conclusions: Surgical deactivation of temporal-triggered migraine headaches is effective regardless of age, sex, or follow-up time. Successful site II surgery is associated with changes in specific symptoms and triggers. This information can assist in trigger avoidance and contribute to constellations used for temporal-triggered migraine headaches trigger-site identification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk of subsequent primary malignancies after dermatofibrosarcoma protuberans diagnosis: A national study

BACKGROUND Patients frequently live many years after diagnosis of dermatofibrosarcoma protuberans (DFSP). OBJECTIVE We sought to determine the risk of subsequent primary malignancy (SPM) after DFSP diagnosis. METHODS Using the Surveillance, Epidemiology, and End Results database (1973-2008) for 3734 patients with DFSP, we compared the risk of developing 14 SPMs (12 most prevalent cancers in the United States plus other nonepithelial and soft tissue) relative to risk in the general population of same sex, race, and age and year of diagnosis. RESULTS Patients given the diagnosis of DFSP had an overall increased risk of SPM (observed:expected [O:E], 1.20; 95% confidence intervals [CI], 1.04-1.39), with much of the overall increased risk attributable to increased risk of nonepithelial skin cancer (O:E, 9.94; 95% CI, 3.38-22.30). Specifically, female patients with DFSP were at increased risk of other nonepithelial skin cancer (O:E, 14.50; 95% CI, 3.46-38.98), melanoma (O:E, 2.59; 95% CI, 1.02-5.35), and breast cancer (O:E, 1.44; 95% CI, 1.00-2.00). Male patients were not at increased overall risk (O:E, 1.18; 95% CI, 0.96-1.44) of SPM or at increased risk of any specific malignancy (P > .05) adjusted for multiplicity of t tests. LIMITATIONS Surveillance bias may have led to increased rates and earlier detection of primary malignances in patients with DFSP compared with the general population. Individual data that may reveal shared environmental causes of DFSP and SPM were unavailable. CONCLUSIONS Patients with DFSP are at increased risk of a number of SPMs.

In-depth Review of Symptoms, Triggers, and Surgical Deactivation of Frontal Migraine Headaches (site I)

Background: This study reports details of the technique and assesses efficacy of surgical deactivation of frontal migraine headaches. In addition, this study examines the effect of surgical deactivation of frontal migraine headaches on migraine triggers and associated symptoms besides the pain. Methods: Charts of 270 patients undergoing surgery performed by a single surgeon for frontal migraine headaches, who were followed for at least 1 year, were analyzed. Median regression adjusted for age, sex, and follow-up time was used to determine postoperative reduction in frontal-specific Migraine Headache Index, which is the product of duration, frequency, and severity. Reduction in migraine-days, which is the product of duration and frequency, was also measured. The association between individual symptom or trigger resolution and frontal-specific Migraine Headache Index reduction was studied by logistic regression. Details of the surgical treatment are discussed and complication rates are reported. Results: Eighty-six percent of patients reported a successful operation (≥50 percent improvement of frontal-specific Migraine Headache Index) at least 12 months after surgery (mean follow-up, 3 years). Eighty-four percent of patients had a successful operation as measured by migraine-days. Fifty-seven percent of patients reported complete elimination of frontal migraine headaches. Symptoms resolving with successful site I surgery beyond the headaches include visual aura and blurred or double vision (p < 0.05). Triggers resolving with successful site I surgery include fatigue, weather change, and missed meals (p < 0.05). Conclusions: Surgical deactivation of frontal migraine headaches provides long-lasting migraine relief. Successful site I surgery is associated with changes in specific symptoms and triggers. This information can assist in trigger avoidance and contribute to constellations used for frontal migraine headache trigger-site identification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Mapping the superficial inferior epigastric system and its connection to the deep system: An MRA analysis

The superficial inferior epigastric vasculature plays a critical role in free abdominal tissue transfer. However, its anatomic variations are incompletely characterized. An investigation was conducted on the preoperative imaging of patients undergoing free-flap breast reconstruction by a single surgeon between 2008 and 2013. This study included patients who underwent abdominal magnetic resonance angiogram (MRA). A coordinate system was used to draw the main trunk and primary branches from each patients superficial inferior epigastric system. Each hemiabdomens branching pattern was categorized as simple, complex, or absent. The number of superficial-to-deep inferior epigastric connections and the presence or absence of a superficial system crossing the midline were recorded. Interrater reliability was assessed for two raters. This analysis included 53 patients (106 hemiabdomens). A total of 80 (75%) hemiabdomens were categorized as having simple and 10 (9%) as complex branching patterns. A total of 16 (15%) hemiabdomens had no identifiable vessels. At least one superficial-to-deep connection was found among 89 hemiabdomens (84%). Superficial systems crossing the midline were found in 14 patients (26%). Our findings support the high degree of anatomic variation in the superficial inferior epigastric system, including a significant number of patients lacking superficial-to-deep connections and bilaterally communicating systems. These variations may be identified on preoperative MRA.

Limited incision harvest of the rectus abdominis muscle flap

BackgroundRectus abdominis muscle harvest typically uses a long and continuous paramedian approach. To limit donor site morbidity, the senior author performs a limited incision approach particularly useful in medically vulnerable patients, including patients with sternal wound infections.MethodsAll patients of a single surgeon from 2000 to 2014 who underwent rectus harvest by one or two transverse incisions and use of lighted retractor were identified. Patients were categorized by indication, for “sternal wound coverage” or “non-sternal wound coverage.” Co-morbidities, operative notes, and post-operative courses were evaluated. Comparisons were made to patients undergoing harvest by paramedian approach.ResultsSeventeen patients with a mean age of 61 underwent limited-incision rectus harvest. Nine patients had indication for “sternal wound coverage.” Three patients had single transverse incision and six patients had double transverse incisions. One patient expired post-reconstruction day 3. One patient had complete abdominal and partial sternal wound dehiscence. No other donor site complications were observed. Eight patients had indication for “non-sternal wound coverage,” including seven patients requiring free rectus for lower extremity defects and one a pedicled rectus abominis for pelvic osteomyelitis. No post-operative complications were observed in these non-sternal wound coverage patients. There was a trend toward improved wound healing and hospitalization time using the transverse compared to paramedian technique, although this was not significant.ConclusionsThe morbidity of the traditional paramedian incision for rectus harvest may be avoided using a limited skin incision approach. This is useful in patients with attenuated healing capacity and offers a lower risk approach to a traditionally risky donor site.Level of Evidence: Level IV, therapeutic study.

Earlobe Rejuvenation: A Fat Grafting Technique.

BACKGROUND The earlobe demonstrates stereotypical signs of aging, including wrinkles and volume depletion. OBJECTIVES The purpose of this study is to review the outcome of the earlobe rejuvenation developed by the senior author. METHODS We describe our earlobe rejuvenation technique refined over 10 years that uses fat grafting to the earlobe. Three raters assessed preoperative and postoperative photographs of 40 earlobes in 20 patients. Each earlobe was evaluated for volume deficiency, number of deep creases, depth of creases, and number of fine wrinkles. Inter-rater reliability was calculated. Earlobe length was also measured. RESULTS Seventeen females and 3 males with average age of 63 years were followed for an average of 26 months. Postoperative improvements were observed in earlobe volume deficiency and number of fine wrinkles (P < .05). Improvements were seen in number and depth of creases and the earlobe height, but these were not significant (P > .05). No complications relating to the earlobe were observed in these patients. CONCLUSIONS Fat grafting can be an effective means for earlobe rejuvenation. LEVEL OF EVIDENCE 4 Therapeutic.