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Outpatient electrodiagnostic studies and intraoperative monitoring are essential tools for the surgical management of nerve injury. Decisions are based on the diagnostic certainty afforded by outpatient electrodiagnostic studies, which are more sensitive and specific than clinical examinations regarding the nature and localization of a nerve lesion. Intraoperative neurophysiologic monitoring detects changes in neurologic function during surgery. It provides significantly better information than visual inspection of the operative field, minimizing postoperative neurologic deficits due to surgical manipulation (e.g., stretching, compression, heating from electrocauterization, constriction, or clamping of local blood vessels). These techniques exploit similar neurophysiologic principles to afford enhanced diagnostic and real-time functional data during surgery. However, an understanding of their limitations is critical for the interpretation of these data. This review discusses these techniques, including their use, advantages, and disadvantages in diagnosing and managing three essential nerve lesions amenable to surgical management-radiculopathy, mononeuropathy, and brachial plexopathy. LESS      Full article

Aim: The purpose of this study is to compare the surgical outcomes of treating recurrent carpal tunnel with recurrent carpal tunnel release only compared to recurrent carpal tunnel release with fat grafting as an adjunct.Methods: Retrospective case-control study was performed of the recurrent carpal tunnels treated, excluding explicit nerve injury such as transections, neuromas in continuity, etc. Patients with recurrent carpal tunnel received re-release of carpal tunnel only or fat grafting as an adjunct. The outcomes of both groups were compared utilizing chi-square analysis.Results: A total number of 81 patients were found to meet the inclusion criteria. Of the recurrences, a total of 16 patients did not receive fat grafting and 65 did. The rate of improvement in symptoms for performing a carpal tunnel release was only 50.0% and for performing carpal tunnel release with fat grafting was 92%, with P-value < 0.00.Conclusion: Adipose-derived stem cells as an adjunct to carpal tunnel release increased the rate of improvement in symptoms of carpal tunnel compression after recurrence compared to carpal tunnel release alone. Further studies need to be performed to confirm the validity of these findings. LESS      Full article

Upper limb loss results in significant physical and psychological impairment and is a major financial burden for both patients and healthcare services. Current myoelectric prostheses rely on electromyographic (EMG) signals captured using surface electrodes placed directly over antagonistic muscles in the residual stump to drive a single degree of freedom in the prosthetic limb (e.g., hand open and close). In the absence of the appropriate muscle groups, patients rely on activation of biceps/triceps muscles alone (together with a mode switch) to control all degrees of freedom of the prosthesis. This is a non-physiological method of control since it is non-intuitive and contributes poorly to daily function. This leads to the high rate of prosthetic abandonment. Targeted muscle reinnervation (TMR) reroutes the ends of nerves in the amputation stump to nerves innervating “spare” muscles in the amputation stump or chest wall. These then become proxies for the missing muscles in the amputated limb. TMR has revolutionised prosthetic control, especially for high-level amputees (e.g., after shoulder disarticulation), resulting in more intuitive, fluid control of the prosthesis. TMR can also reduce the intensity of symptoms such as neuroma and phantom limb pain. Regenerative peripheral nerve interface (RPNI) is another technique for increasing the number of control signals without the limitations of finding suitable target muscles imposed by TMR. This involves wrapping a block of muscle around the free nerve ending, providing the regenerating axons with a target organ for reinnervation. These RPNIs act as signal amplifiers of the previously severed nerves and their EMG signals can be used to control prosthetic limbs. RPNI can also reduce neuroma and phantom limb pain. In this review article, we discuss the surgical technique of TMR and RPNI and present outcomes from our experience with TMR. LESS      Full article

Aim: Targeted muscle reinnervation (TMR) is a procedure pioneered to improve control of myoelectric prostheses and was fortuitously found to improve postamputation pain by transferring residual nerve ends from an amputated limb to reinnervate motor nerve units in denervated muscles. This study sought to perform a systematic review of the literature regarding the postamputation pain-related outcomes following TMR.Methods: PubMed database was queried using the key term “targeted muscle reinnervation”. Articles were chosen based on the following criteria: (1) clinical studies on TMR; (2) greater than one subject; (3) studies were case-controls, comparative cohort analyses, controlled trials, or randomized controlled trials; and (4) studies included one or more outcomes of interest: prosthetic use and functionality, improvement or persistence of pain, indications, complications, donor nerves, and technical aspects of TMR.Results: Overall, 9 studies including 101 upper extremity and 252 lower extremity nerve transfers were analyzed, with nerve transfer type, amputation location, and specific neurotizations reported. Four studies assessed the efficacy of TMR in addressing phantom limb pain (PLP) and residual limb pain (RLP), with 3 out of 4 studies reporting significant improvements in PROMIS (Patient Reported Outcome Measurement Information System) scores in TMR subjects compared to controls. Five additional studies did not analyze PROMIS scores but reported subjective improvements in pain outcomes.Conclusion: Included studies demonstrated TMR had lower maximal pain and pain intensity, behavior and interference compared to the standard of care. Secondary TMR used to treat patients with established painful neuromas also reported improvement in pain compared to baseline. LESS      Full article

Restoration of upper extremity function poses a unique surgical challenge. With considerations ranging from ensuring appropriate skeletal support and musculotendinous and ligamentous anatomy, restoring adequate vascularity and innervation, and providing sufficient soft tissue coverage, upper extremity injuries present a diverse range of reconstructive problems. Recent history has been marked by an expansion of novel techniques for addressing these complex issues. Sophisticated modalities, such as targeted muscle reinnervation, free functional muscle transfer, and vascularized composite allotransplantation, have become some of the most powerful tools in the armamentarium of the reconstructive surgeon. This review article aims to define the distinguishing features of each of these modalities and reviews some of their unique advantages and limitations. LESS      Full article

Aim: Biosynthetic scaffolds represent cutting-edge therapeutic efforts for secondary lymphedema. In particular, nanofibrillar collagen scaffolds have shown efficacy in both preclinical and clinical contexts, and there has been growing interest in these scaffolds in recent years. This study systematically reviewed the current literature on nanofibrillar collagen scaffolds for lymphedema treatment to synthesize findings and highlight areas for further research.Methods: This was a systematic scoping review of the literature on nanofibrillar collagen scaffolds for lymphedema treatment.Results: Upon review of the literature, 32 relevant articles were identified, of which seven articles specifically investigating nanofibrillar collagen scaffolds were selected for inclusion. Of these articles, three investigated scaffold placement in small or large animal models, while four were clinical investigations ranging from case reports to retrospective cohort studies. Across all studies, scaffold implantation was associated with significant improvement in lymphedema symptoms compared to untreated controls, especially when used in combination with physiologic microsurgical procedures such as vascularized lymph node transfer. However, even when used alone or in combination with lymph node fragments, subcutaneous placement of these scaffolds improved lymphedema symptoms. Additionally, in a rodent model of lymphedema, scaffold placement at the time of lymph node harvest forestalled the development of lymphedema, highlighting the preventative capacity of these scaffolds as well. Conclusion: Nanofibrillar collagen scaffolds have been demonstrated to effectively treat and/or prevent secondary lymphedema in both preclinical and clinical investigations. Ultimately, these scaffolds represent a promising intersection of tissue engineering and lymphedema therapy, and further clinical investigation is warranted. LESS      Full article

Collagen-based supplements have become a keystone in the management of the ageing process, with proven ability to repair skin damage, bestowing a youthful and healthy appearance sought in the pursuit of beauty. Collagen is an essential scaffold protein that gives smoothness and elasticity to skin, but its production declines with age. Finding ways to tackle this problem is now strongly promoted as an effective way to transform skin and hair, repairing age-related deterioration. A growing number of scientific studies show exciting evidence that it is possible to rejuvenate ageing or damaged skin, improve function of worn joints, and support personal wellbeing and vitality. In recent times, research on the mechanisms which impact the production of collagen in skin and the ideal organization into functional fibres which give skin its characteristic elasticity and firmness has provided new insights into how this bio-scaffold can support cells, tissues and organs. The factors which influence collagen production over a lifetime (e.g., puberty, pregnancy, menopause, andropause), intrinsic factors (e.g., genetics, age, ethnicity) and extrinsic factors (e.g., UV-radiation, pollution, smoking) and the potential for new technologies, ingredients and devices to restore collagen and matrix components to their optimal condition are improving the ability to deliver anti-aging strategies with unprecedented results. This paper will review skin collagen production, structure and function throughout the lifestages, emphasizing its relationship with health, appearance and beauty. LESS      Full article

Periodontal tissue engineering involves a multi-disciplinary approach towards the regeneration of periodontal ligament, cementum and alveolar bone surrounding teeth, whereas bone regeneration specifically applies to ridge reconstruction in preparation for future implant placement, sinus floor augmentation and regeneration of peri-implant osseous defects. Successful periodontal regeneration is based on verifiable cementogenesis on the root surface, oblique insertion of periodontal ligament fibers and formation of new and vital supporting bone. Ultimately, regenerated periodontal and peri-implant support must be able to interface with surrounding host tissues in an integrated manner, withstand biomechanical forces resulting from mastication, and restore normal function and structure. Current regenerative approaches utilized in everyday clinical practice are mainly guided tissue/bone regeneration-based. Although these approaches have shown positive outcomes for small and medium-sized defects, predictability of clinical outcomes is heavily dependent on the defect morphology and clinical case selection. In many cases, it is still challenging to achieve predictable regenerative outcomes utilizing current approaches. Periodontal tissue engineering and bone regeneration (PTEBR) aims to improve the state of patient care by promoting reconstitution of damaged and lost tissues through the use of growth factors and signaling molecules, scaffolds, cells and gene therapy. The present narrative review discusses key advancements in PTEBR including current and future trends in preclinical and clinical research, as well as the potential for clinical translatability. LESS      Full article

Neck aesthetics are a vital and indispensable component of cervicofacial beauty. Cosmetic deformities may be due to congenital or acquired etiologies and successful management depends on accurately diagnosing the underlying anatomical problems and applying the appropriate surgical and non-surgical procedures to achieve the desired result. For clinical evaluation and treatment, neck anatomy may be conceptualized into three layers wherein the superficial layer consists of the skin and subcutaneous fat, the intermediate layer of platysma muscle and interplatysmal fat, and the deep layer of subplatysmal fat, digastric muscles, submandibular glands, and skeletal support structures. The goal of this article is to review neck aesthetics, cosmetic deformities, and indications for different treatment techniques by way of a systematic layered approach. LESS      Full article

Aim: Improving the cervical contour is one of the main goals of patients seeking face and neck rejuvenation. However, little attention has been dedicated to refine the anterior border of the sternocleidomastoid muscles and to improve the inferior neck. In this study, the authors sought to describe new surgical tactics to address these issues.Methods: The records of 1,019 patients were evaluated retrospectively. Surgical strategies to treat the neck were reviewed and two new approaches, described. Plication of the sternohyoid muscles and lateral plication of the platysma along the anterior border of the sternocleidomastoid muscles are detailed and supplemented with a video.Results: Of the 1,019 patients, 937 patients (91.9%) underwent subplatysmal neck lift. Three-hundred-and-forty-eight patients (34.1%) underwent sternohyoid muscles plication, and 784 patients (76.9%) had rejuvenation of the sternocleidomastoid muscles. The most common complication was weakness of the lower lip depressors [79 patients (7.7%)].Conclusion: Approaching the sternohyoid muscles and rejuvenating the sternocleidomastoid muscles are new reliable and effective tactics to optimize results in neck lifts. LESS      Full article