BACKGROUND: Following traumatic finger amputation, successful replantation depends on several preoperative factors, with proximity to a registered hand trauma center being a key determinant. These centers represent the s...BACKGROUND: Following traumatic finger amputation, successful replantation depends on several preoperative factors, with proximity to a registered hand trauma center being a key determinant. These centers represent the standard for treatment, making timely access within a critical window essential. Research has demonstrated that increased travel distances and longer times to replantation correlate with poorer functional outcomes. METHODS: Using data from the American Society for Surgery of the Hand, the locations of registered hand trauma centers were mapped with advanced isochrone application programming interface modeling software, which uses complex algorithms to map and analyze areas reachable within specific time or distance thresholds. A shaded region was generated to indicate areas within a 6-hour and 12-hour travel radius of a registered hospital center. RESULTS: The District of Columbia (1.5), Oklahoma (0.98), and Minnesota (0.88) had the highest number of trauma centers per 1 million residents, whereas multiple states such as Nevada, Montana, and Kansas had 0 trauma centers. In terms of geospatial mapping, regions such as Houston, Texas; Indianapolis, Indiana; Columbus and Cincinnati, Ohio; and large cities in the Northeast such as New York, Philadelphia, the District of Columbia, and Boston, all have greater than 6 hand trauma centers. At a 6-hour catchment, 13.3% of the U.S. population lacks access to a registered hand trauma center; even when extended to 12 hours, 7.6% remain without coverage. CONCLUSIONS: Limited hospital and trauma center density remains a significant barrier to high-quality surgical care. Reducing travel times, increasing access in rural areas, and improving urban infrastructure could enhance replantation outcomes by ensuring that more patients reach registered hand trauma centers within the critical time window.
BACKGROUND: Surgical decompression of the greater occipital nerve (GON) is a recognized treatment for occipital migraines that are resistant to medical management. Recent evidence suggests that vascular compression by th...BACKGROUND: Surgical decompression of the greater occipital nerve (GON) is a recognized treatment for occipital migraines that are resistant to medical management. Recent evidence suggests that vascular compression by the occipital artery (OA) contributes to occipital migraine pathophysiology. This study compared postoperative outcomes between endoscopic-assisted radical GON decompression along its entire course with complete OA elimination and standard open GON decompression with limited proximal OA elimination. METHODS: A retrospective review was performed on 85 patients who underwent endoscopic-assisted (n=74) or open GON decompression (n=11). Outcomes included changes in migraine headache index (MHI), migraine intensity, frequency, and duration. Cox regression analysis evaluated the probability of achieving a 90% reduction in migraine frequency and MHI over 35 months. RESULTS: Both surgical techniques resulted in significant improvements in MHI, intensity, duration, and frequency (p<0.01 for all measures). The endoscopic-assisted group demonstrated greater reductions in MHI (-182.11 vs. -152.85, p=0.17), frequency (-20.90 vs. -15.45, p=0.08), and intensity (-5.44 vs. -3.00, p<0.001) compared to the open group. Complete migraine resolution rates were also significantly higher in the endoscopic group (69.8% vs. 45.0%, p=0.04). Cox regression analysis showed that endoscopic-assisted decompression was associated with a significantly higher likelihood of maintaining a 90% reduction in migraine frequency and MHI over 36 months. CONCLUSIONS: Endoscopic-assisted GON decompression with complete OA resection is more effective than open decompression in achieving and sustaining occipital migraine relief. These findings underscore the key role of vascular compression in migraine pathogenesis and highlight endoscopic-assisted decompression as the preferred surgical approach.
BACKGROUND: Lymphedema related to breast cancer is a common and debilitating complication following axillary lymph node dissection (ALND) and regional nodal irradiation. It leads to substantial long-term morbidity and ec...BACKGROUND: Lymphedema related to breast cancer is a common and debilitating complication following axillary lymph node dissection (ALND) and regional nodal irradiation. It leads to substantial long-term morbidity and economic burden. Effective prevention strategies are essential to improving quality of life and reducing healthcare costs. METHODS: A model-based cost-effectiveness analysis was conducted from a payer perspective using a decision tree framework. Literature-based inputs informed the model, and patients were stratified into five oncologic treatment cohorts involving various combinations of surgery, chemotherapy, and radiation. The base case was a 45-year-old undergoing ALND for stage III breast cancer. Three prevention strategies were evaluated: the immediate lymphatic reconstruction (ILR), prospective surveillance, and no specific intervention. Outcomes included total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity analyses tested model robustness. RESULTS: Both prospective surveillance and ILR were cost-effective compared to no intervention. No intervention yielded the lowest cost ($10,774) and lowest effectiveness (17.94 QALYs). Prospective surveillance improved outcomes at minimal additional cost ($11,415; 19.85 QALYs), with an ICER of $344/QALY. ILR provided the greatest health benefit and incurred the highest cost ($15,426; 22.35 QALYs), but its ICER ($1,607/QALY) remained well below the willingness-to-pay threshold. Sensitivity analyses confirmed robust findings across varied inputs. CONCLUSIONS: ILR and prospective surveillance are cost-effective strategies for preventing lymphedema following ALND. ILR offers the greatest health benefit and supports broader integration of preventive microsurgical approaches into multidisciplinary breast cancer care.
BACKGROUND: As limitations of nasoalveolar molding (NAM), including labor intensity and reliance on specialized expertise and infrastructure, have become increasingly evident, interest has shifted toward simplified presu...BACKGROUND: As limitations of nasoalveolar molding (NAM), including labor intensity and reliance on specialized expertise and infrastructure, have become increasingly evident, interest has shifted toward simplified presurgical infant orthopedics (PSIO). Nasal Elevator (NE)-based protocols and the recently introduced Presurgical Lip-Alveolus-Nose Approximation (PLANA) represent such alternatives. However, these two simplified approaches have not been directly compared using objective three-dimensional analysis and a validated anthropometric grading system. This study compared NE-based PSIO and PLANA in infants with unilateral cleft lip. METHODS: Consecutive cohorts of 26 infants treated with NE (2023-2024) and 23 infants treated with PLANA (2024-2025) were analyzed; all PSIO was performed by the same surgeon. Cleft severity (four levels) and PSIO outcomes (Excellent/Good/Poor) were assessed using a validated anthropometric grading system based on nostril width ratio (NWR), columellar angle (CA), and subnasale lateral displacement (SN). Groups were compared using Fisher's exact test, chi-square testing, and Mann-Whitney U test (p < 0.05). RESULTS: Baseline characteristics were comparable between groups. PLANA achieved a more favorable post-PSIO severity distribution (p = 0.049) and a higher proportion of Excellent outcomes with fewer Poor outcomes (χ² = 7.48, p = 0.024). Improvement in SN was significantly greater with PLANA (p = 0.04), whereas improvements in NWR and CA were comparable between techniques. CONCLUSIONS: Both NE-based PSIO and PLANA improved nasolabial morphology in unilateral cleft lip. However, PLANA demonstrated superior presurgical orthopedic effectiveness, particularly in subnasale alignment, supporting its role as an effective and scalable PSIO strategy.
INTRODUCTION: An increasing number of women present for mastectomy and reconstruction following prior lumpectomy and irradiation, also known as breast-conserving therapy (BCT). While reconstruction after postmastectomy r...INTRODUCTION: An increasing number of women present for mastectomy and reconstruction following prior lumpectomy and irradiation, also known as breast-conserving therapy (BCT). While reconstruction after postmastectomy radiotherapy is well studied, outcomes following prior BCT remain less clearly defined. This study aimed to compare reconstructive outcomes in patients with a history of BCT. METHODS: A retrospective review of patients with autologous or implant-based reconstructions with a history of BCT between January 2017 and March 2025 was performed. Patients were compared with radiation-naïve controls and reconstructive outcomes were compared. Propensity score matching was used to minimize selection bias. Complications were categorized as major, minor, or any complication. RESULTS: In the matched autologous cohort, 50 BCT patients were matched to 200 radiation-naïve patients; those with prior BCT experienced higher rates of any complication (36.0% vs 20.0%, p=0.02), mainly caused by higher infection (8.0% vs 3.0%, p=0.2) and mastectomy skin flap necrosis (10.0% vs 3.5%, 0.07). In the matched implant-based cohort (49 BCT, 490 radiation-naïve), patients with prior BCT experienced significantly higher rates for major, minor and any complications (all p≤0.001). When comparing autologous BCT to implant-based BCT (45 matched in each), autologous reconstruction experienced lower rates of reconstruction failure (2.2% vs 24.4%, p<0.001). Other complications were comparable. CONCLUSION: A history of BCT is associated with increased postoperative complications following breast reconstruction, particularly in implant-based reconstructions. Autologous reconstruction offers lower failure rates in this population and should be strongly considered when feasible.
OBJECTIVES: Vulvar lichen sclerosus (VLS) is a chronic condition. If untreated, it may lead to anatomical modifications, including introital stenosis, which may impact sexual function and quality of life. First line trea...OBJECTIVES: Vulvar lichen sclerosus (VLS) is a chronic condition. If untreated, it may lead to anatomical modifications, including introital stenosis, which may impact sexual function and quality of life. First line treatment with topical corticosteroids is not effective in a variable percentage of patients. This study aims to assess the effectiveness of a surgical procedure that combines vulvar widening through perineal flap transposition, rigottomy, and fat grafting for VLS-related introital stenosis. METHODS: A retrospective study included 35 women aged 18-85 with VLS-related introital stenosis who underwent the combined surgical procedure between 2010 and 2019. The surgical technique involved vulvar widening through vulvar flaps, rigottomy, and fat grafting. At the time of followup, which occurred in 2021, we evaluated: patient satisfaction, symptom severity, sexual function, quality of life, psychological well-being, vulvar architecture, and frequency of on-demand topical corticosteroids usage. RESULTS: 88.5% of patients were satisfied with the procedure. Significant improvements were observed in symptoms (p<0.05), psychological wellbeing (p<0.05), and quality of life (p<0.05) 6 and 12 months postsurgery. Sexual function also improved, although not significantly for all items of the questionnaire. Vulvar architecture was improved in 60% of cases. The need for topical corticosteroids was significantly reduced (p<0.002), with 85.7% of patients reporting no or on-demand usage. CONCLUSION: This approach offers a promising solution for severe VLS-related vulvar stenosis. Despite the retrospective nature of the study and its sample size, the long-term follow-up (up to eleven years) adds strength to the findings.