Jennifer E. Cheesborough

Targeted Muscle Reinnervation and Advanced Prosthetic Arms

Targeted muscle reinnervation (TMR) is a surgical procedure used to improve the control of upper limb prostheses. Residual nerves from the amputated limb are transferred to reinnervate new muscle targets that have otherwise lost their function. These reinnervated muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of advanced prosthetic arms. Here the authors provide a review of surgical techniques for TMR in patients with either transhumeral or shoulder disarticulation amputations. They also discuss how TMR may act synergistically with recent advances in prosthetic arm technologies to improve prosthesis controllability. Discussion of TMR and prosthesis control is presented in the context of a 41-year-old man with a left-side shoulder disarticulation and a right-side transhumeral amputation. This patient underwent bilateral TMR surgery and was fit with advanced pattern-recognition myoelectric prostheses.

Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs

Background: Standard abdominoplasty rectus plication techniques may not suffice for severe cases of rectus diastasis. In the authors’ experience, prosthetic mesh facilitates the repair of severe rectus diastasis with or without concomitant ventral hernias. Methods: A retrospective review of all abdominal wall surgery patients treated in the past 8 years by the senior author (G.A.D.) was performed. Patients with abdominoplasty and either rectus diastasis repair with mesh or a combined ventral hernia repair were analyzed. Results: Thirty-two patients, 29 women and three men, underwent mesh-reinforced midline repair with horizontal or vertical abdominoplasty. Patient characteristics included the following: mean age, 53 years; mean body mass index, 26 kg/m2; average width of diastasis or hernia, 6.7 cm; and average surgery time, 151 minutes. There were no surgical-site infections and two surgical-site occurrences—two seromas treated with drainage in the office. After an average of 471 days’ follow-up, none of the patients had recurrence of a bulge or a hernia. Conclusions: For patients with significant rectus diastasis, with or without concomitant hernias, the described mesh repair is both safe and durable. Although this operation requires additional dissection and placement of prosthetic mesh in the retrorectus plane, it may be safely combined with standard horizontal or vertical abdominoplasty skin excision techniques to provide an aesthetically pleasing overall result. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Targeted muscle reinnervation in the initial management of traumatic upper extremity amputation injury

Targeted muscle reinnervation (TMR) was initially designed to provide cortical control of upper limb prostheses through a series of novel nerve transfers. Early experience has suggested that TMR may also inhibit symptomatic neuroma formation. We present the first report of TMR performed at the time of a traumatic shoulder disarticulation. The procedure was done to prevent painful neuroma pain and allow for myoelecteric prosthetic use in the future. Eight months post-operatively, the patient demonstrates multiple successful nerve transfers and exhibits no evidence of neuroma pain on clinical exam. Using the Patient Reported Outcomes Measurement Information System (PROMIS), the patient demonstrates minimal pain interference or pain behavior. Targeted muscle reinnervation may be considered in the acute trauma setting to prevent neuroma pain and to prepare patients for myoelectric prostheses in the future.

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts.

BACKGROUND Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. METHODS A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. RESULTS The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. CONCLUSIONS With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

Prospective repair of Ventral Hernia Working Group type 3 and 4 abdominal wall defects with condensed polytetrafluoroethylene (MotifMESH) mesh

BACKGROUND Treatment of clean-contaminated and contaminated ventral hernia defects remains controversial. Newer prosthetic materials may play an important role in these patients. METHODS Ten patients with Ventral Hernia Working Group types 3 and 4 were prospectively enrolled and subsequently treated with direct supported repairs with condensed fenestrated polytetrafluoroethylene mesh. The primary outcome was hernia occurrence at 1 year after surgery. Secondary outcomes included surgical site infection, surgical site occurrence, medical complications, pain, and other patient-reported outcomes. RESULTS There were no immediate postoperative infections and one minor postoperative hematoma treated in the office. One patient required delayed mesh removal 9 months after placement. Importantly, the mesh removal procedure was straightforward because of the material properties of the mesh. Of the 9 patients still with mesh, there were no hernia recurrences at the repair site with one full year of follow-up. CONCLUSION Contaminated and clean-contaminated abdominal wall defects can be effectively and durably treated with condensed polytetrafluoroethylene mesh.

Advances in Transfemoral Amputee Rehabilitation: Early Experience with Targeted Muscle Reinnervation

While myoelectric prosthetic devices have been used for decades in the upper extremities, only recently have motorized knee and ankle components proven durable and effective enough for use in the lower extremity amputee. The control schemes developed to capitalize on these prosthetic advances must take into account the biomechanical differences between upper and lower extremity function. Already a valuable adjunct for the myoelectric control of upper extremity prostheses, targeted muscle reinnervation in the transfemoral amputee offers the potential to further enhance lower extremity prosthesis control and may simultaneously address post-amputation neuroma pain. Current strategies for lower extremity prosthesis control are discussed, along with a review of the transfemoral TMR technique and early clinical experience.

Striking a Better Integration of Work and Life: Challenges and Solutions

Summary: Plastic surgeons are a diverse group but share a drive for excellence and dedication to their patients and the advancement of the specialty. Long hours at work and the need to be on call have limited the time that many have to spend on activities outside of the workplace. Reconciliation of the demands of surgery and private life can at times seem impossible. A failure to achieve balance between work and home life is associated with reduced job and life satisfaction, impaired mental health, family conflict, and ultimately burnout. Although the obstacles are many and varied, the authors have attempted to identify the challenges and propose solutions. The authors focus on women in plastic surgery in this article, but acknowledge that these issues are not unique to women or plastic surgery.

Treatment of Foot and Ankle Neuroma Pain With Processed Nerve Allografts.

Background: Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity. Methods: A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery. Results: Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002). Conclusion: The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy. Level of Evidence: Level IV, retrospective case series.

Resolution of Cosmetic Buttock Injection-induced Inflammatory Reaction and Heart Failure after Excision of Filler Material

We present a case of a 66-year-old woman who developed heart failure and severe inflammatory reaction after the illicit cosmetic injections of polymethyl-methacrylate or polyacrylamide hydrogel from a primary care provider. After medical optimization, an en bloc excision of all injectable materials and gluteus muscle was performed, which resulted in exposure of bilateral sciatic nerves. Within 10 days, the patients heart failure resolved and inflammatory state improved. This is the first known report of heart failure due to buttock injections and subsequent improvement after surgery.

Post-excisional Wound Closure Chapter for Rural Surgeons

Repair of any skin defect is determined primarily by the size of the defect and the laxity of the surrounding skin. Approximating the edges of any defect with reasonable tension depends on the mobility of the neighboring tissue, which varies according to the location. For instance, closing an abdominal defect primarily is easier than closing a sternal defect or one over the shoulder area. Similarly, as a general rule, the more distal an extremity wound is, the more challenging the reconstruction becomes. The first step in any reconstructive procedure is to define the defect fully. While the dimensions of the defect are important, one must also consider the quality of the skin and subcutaneous tissue, the type of tissue at the base of the wound and the surrounding structures. Many wounds can be closed primarily provided that sufficient undermining is performed to allow for minimum tension on the skin edges. Other wounds may require tissue recruitment from the surrounding skin in the form of rotation or advancement flaps, or skin grafting from distant donor sites.