Shai M. Rozen

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.

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.

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.

Computed-tomography modeled polyether ether ketone (PEEK) implants in revision cranioplasty

PURPOSE Traditional cranioplasty methods focus on pre-operative or intraoperative hand molding. Recently, CT-guided polyether ether ketone (PEEK) plate reconstruction enables precise, time-saving reconstruction. This case series aims to show a single institution experience with use of PEEK cranioplasty as an effective, safe, precise, reusable, and time-saving cranioplasty technique in large, complex cranial defects. METHODS We performed a 6-year retrospective review of cranioplasty procedures performed at our affiliated hospitals using PEEK implants. A total of nineteen patients underwent twenty-two cranioplasty procedures. Pre-operative, intra-operative, and post-operative data was collected. RESULTS Nineteen patients underwent twenty-two procedures. Time interval from injury to loss of primary cranioplasty averaged 57.7 months (0-336 mo); 4.0 months (n=10, range 0-19) in cases of trauma. Time interval from primary cranioplasty loss to PEEK cranioplasty was 11.8 months for infection (n=11, range 6-25 mo), 12.2 months for trauma (n=5, range 2-27 mo), and 0.3 months for cosmetic or functional reconstructions (n=3, range 0-1). Similar surgical techniques were used in all patients. Drains were placed in 11/22 procedures. Varying techniques were used in skin closure, including adjacent tissue transfer (4/22) and free tissue transfer (1/22). The PEEK plate required modification in four procedures. Three patients had reoperation following PEEK plate reconstruction. CONCLUSION Cranioplasty utilizing CT-guided PEEK plate allows easy inset, anatomic accuracy, mirror image aesthetics, simplification of complex 3D defects, and potential time savings. Additionally, its easily manipulated in the operating room, and can be easily re-utilized in cases of intraoperative course changes or infection.

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.

Upper Eyelid Postseptal Weight Placement for Treatment of Paralytic Lagophthalmos

Background: Left untreated, paralytic lagophthalmos may result in corneal dryness, ulcerations, and subsequent blindness. The most common nondynamic surgical solution is upper eyelid weight placement in a superficial, pretarsal pocket, carrying the risk of visibility, extrusion, and entropion. The authors present a technique useful in patients presenting with either primary symptoms of corneal exposure or complications of previous implants that is equally efficacious, with a potentially decreased risk of complications, in which the weight is inserted into a deeper, postseptal position but requires use of a heavier weight. Methods: Nineteen patients, 15 primary and four secondary, treated between the years 2008 and 2012 with the postseptal approach, were evaluated for demographics, cause, resolution of primary symptoms, and complications. The average weight difference between that measured in the clinic versus weight used in surgery in the primary group and the average weight difference between that inserted in previous surgery versus weight placed in corrective surgery were calculated. Results: The average weight difference was 0.213 g (range, 0 to 0.4 g) in the primary group and 0.2 g (range, 0 to 0.4 g) in the revision group. Symptoms resolved in all but one patient, neither revisions nor complications were noted, and the longest follow-up was 4 years. Conclusions: The retroseptal technique has proven to be safe, reproducible, and very useful in both primary and secondary upper eyelid surgery for paralytic lagophthalmos. It successfully addresses several common problems encountered with more superficial weight placement, including visibility, exposure, and entropion, but often necessitates use of a heavier weight. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reconstruction of the inferior alveolar nerve with bioabsorbable polyglycolic acid nerve conduits

Background: Iatrogenic injury to the inferior alveolar nerve can result in debilitating anesthesia, dysesthesia, and allodynia. The authors report their experience with polyglycolic acid nerve tubes in inferior alveolar nerve reconstruction. Methods: Five patients with iatrogenically injured inferior alveolar nerves underwent reconstruction with polyglycolic acid nerve tubes performed by the senior author (A.P.T.). Patient charts were reviewed retrospectively. Resolution of pain, narcotic medication use, neuropathic pain medication use, and patient satisfaction with surgery were assessed by means of patient surveys. Sensation recovery was assessed with the Ten Test. Costs of surgery were calculated and adjusted to 2010 U.S. dollars using the consumer price index. Results: Survey response rate was 100 percent. All patients suffered from preoperative pain and sensation loss. Preoperatively, 80 percent of patients used prescription narcotic and 100 percent of patients used neuropathic pain medications. Average time from injury to reconstruction was 14 months. Operative time averaged 240 minutes, and total surgical costs averaged

Double innervated free functional muscle transfer for facial reanimation

8177. At average follow-up of 47.8 months, Ten Test results averaged 3.3. Average time to maximum recovery of sensation and reduction of pain was 8 months and 7 months, respectively. One hundred percent of patients experienced pain relief, with an average 46 percent reduction in pain. Postoperatively, 100 percent of patients discontinued all narcotic and neuropathic pain medications. Conclusions: The use of polyglycolic acid nerve tubes in the reconstruction of iatrogenically injured inferior alveolar nerves achieves diminution of pain and variable sensory recovery. This technique is cost effective and carries no donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

CT-guided Perineural Injections for Chronic Pelvic Pain

Abstract Background: The treatment of long-standing facial palsy represents a challenge for the reconstructive surgeon. Treatment is based on dynamic procedures such as functional muscle flaps. The benefit of added axonal load has recently been reported. This study describes a two stage technique involving dual innervation of a gracilis muscle flap with initial cross-facial nerve graft (CFNG) followed by free muscle transfer co-apted to both the CFNG and a masseter nerve for facial reanimation. Methods: A total of nine patients from August 2008–July 2011 were operated on with the double innervated gracilis muscle flap. Pre- and postoperative electromyography was documented, and video analysis with the five-stage classification of reanimation outcomes was performed. Results: All patients recovered voluntary and spontaneous smile abilities, with an average of 70% motor unit recruitment. Based on the Terzis reanimation outcome classification, four patients had an excellent result, four good, and one moderate. Conclusions: The double innervated gracilis muscle flap is a viable technique for the treatment of long-standing facial palsy. It enables a fast recovery with fast muscle activity, and allows an emotional smile and aesthetic symmetry.

Involuntary movement during mastication in patients with long-term facial paralysis reanimated with a partial gracilis free neuromuscular flap innervated by the masseteric nerve

Chronic pelvic pain is a disabling condition that affects a large number of men and women. It may occur after a known inciting event, or it could be idiopathic. A common cause of pelvic pain syndrome is neuropathy of the pelvic nerves, including the femoral and genitofemoral nerves, ilioinguinal and iliohypogastric nerves, pudendal nerve, obturator nerve, lateral and posterior femoral cutaneous nerves, inferior cluneal nerves, inferior rectal nerve, sciatic nerve, superior gluteal nerve, and the spinal nerve roots. Pelvic neuropathy may result from entrapment, trauma, inflammation, or compression or may be iatrogenic, secondary to surgical procedures. Imaging-guided nerve blocks can be used for diagnostic and therapeutic management of pelvic neuropathies. Ultrasonography (US)-guided injections are useful for superficial locations; however, there can be limitations with US, such as its operator dependence, the required skill, and the difficulty in depicting various superficial and deep pelvic nerves. Magnetic resonance (MR) imaging-guided injections are radiation free and lead to easy depiction of the nerve because of the superior soft-tissue contrast; although the expense, the required skill, and the limited availability of MR imaging are major hindrances to its widespread use for this purpose. Computed tomography (CT)-guided injections are becoming popular because of the wide availability of CT scanners, the lower cost, and the shorter amount of time required to perform these injections. This article outlines the technique of perineural injection of major pelvic nerves, illustrates the different target sites with representative case examples, and discusses the pitfalls. (©)RSNA, 2016.