Background Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying. Questions/purposes (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? Methods Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. Results By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). Conclusions Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. Level of Evidence Level IV, therapeutic study.

Background Mastectomy flap necrosis is the source of considerable morbidity and cost following breast reconstruction. A great deal of effort has been put forth to predicting and even preventing its incidence intraoperatively. Methods A review of the literature was performed evaluating the evidence of mastectomy skin flap perfusion technologies. Results Multiple technologies have leveraged spectroscopy and/or angiography to provide real-time assessment of flap perfusion, including indocyanine green, fluorescein, and light-based devices. Conclusion This manuscript endeavors to review the evidence on mastectomy skin flap perfusion analysis, highlighting the benefits, and downsides of the current technologies and identifying exciting areas of future research and development.

Summary: Furlow palatoplasty is increasingly used both for primary palatoplasty and for secondary correction of velopharyngeal insufficiency. Although Furlow palatoplasty offers the advantage of lengthening the palate, the most tenuous component of the oral mucosal repair is anterior transposition of the oral mucosal Z-plasty flap, with superficial separation of the oral mucosa observed in up to 53 percent of cases of secondary Furlow palatoplasty. To mitigate this problem, the authors prophylactically placed pedicled buccal fat pad flaps to provide an additional vascular layer to promote healing of the overlying oral mucosal Z-plasty flap. The authors report their experience comprising seven patients who underwent Furlow palatoplasty with buccal fat flap augmentation. Four of these patients had secondary Furlow palatoplasty procedures; one of them experienced oral mucosal separation that healed uneventfully. No patients developed an oronasal fistula. The authors’ experience suggests that buccal fat flaps may minimize vascular compromise and dehiscence of the oral mucosal Z-plasty following Furlow palatoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis. Methods: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy. Results: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84). Conclusions: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Background: There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes. Methods: A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis. Results: After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders. Conclusions: Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Risk, II.

No abstract

Background: As fat grafting in breast reconstruction evolves, questions of technique and outcomes persist. We compared 2 common fat processing techniques—decantation (DEC) versus closed wash and filtration (CWF)—with regard to outcomes and efficacy. Methods: Chart review of a single surgeon experience with breast fat grafting was performed. Data extracted included demographics, technique, complications, graft volume, and revision rates. Secondarily, the timeline of complication profiles was analyzed. Lastly, subgroup analysis of radiated versus nonradiated breast outcomes was performed. Results: One thousand one hundred fifty-eight fat grafting procedures were performed on 775 breasts (654 DEC, 504 CWF). Time-to-event analysis for all complications showed no difference between groups. Independent risk factors for fat necrosis included DEC technique, body mass index >30 kg/m2, and fat injection >75 mL. The majority of cases of fat necrosis, cyst/nodule formation, ultrasounds, and biopsies occurred more than 6 months after grafting. Average graft volume was lower in DEC compared with CWF breasts (50.6 versus 105.0 mL, P < 0.01), and more DEC breasts required repeat fat grafting procedures (39.9% versus 29.6%, P < 0.01). Radiated breasts received larger fat graft volume (89.9 versus 72.4 mL, P < 0.01) and required more fat graft procedures (average 1.62 versus 1.47, P < 0.01). Conclusions: This study represents the largest series of breast reconstruction fat grafting to date. DEC harvest technique may be a risk factor for fat necrosis, which results in less fat injection and greater need for repeat procedures. Similarly, radiated breasts require larger graft volume and more repeat procedures.