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Introduction Schwannomas represent benign peripheral nerve sheath tumors. Their phenotypic presentations in schwannomatosis and segmental schwannomatosis have been well described. To date, however, cases of schwannomatosis or multiple schwannomas localized to a single nerve fascicle have been limited in the literature. Case Presentation In this study, we identify a case of a 48 year-old non-neurofibromatosis male who presented with symptomatic schwannomas localized to a single nerve fascicle of the upper extremity. Intraoperative exploration revealed four schwannomas arising from a 15-cm segment of ulnar nerve fascicle. Surgical excision was successful, without neurological deficit or recurrence. Conclusion This study identifies a case of schwannomatosis localized to a single nerve fascicle that may represent a linear variant of segmental schwannomatosis. The presentation may represent a temporary linear appearance in progression to "nonlinear" segmental variant; however, a molecularly distinct subset of schwannomas cannot be excluded.

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BACKGROUND: The effect of obliquity of tendon laceration on repair strength is not well studied. The overwhelming majority of biomechanical studies assess repair strength following a laceration that is perpendicular to the long axis of the tendon. The aim of this study was to investigate whether the angle of tendon laceration affects the core suture strength. METHODS: In all, 110 fresh human cadaveric flexor tendons were cut at varying angles of 15°, 30°, 45°, and 60° and the control group at 90°. All tendons were repaired with 6-strand modified Tang technique. The repair strength was tested using a custom-made tensioning machine, and the initial static gap force and the ultimate breaking force were measured. RESULTS: The mean gap force and 95% confidence interval (CI) for the 15°, 30°, 45°, 60°, and 90° groups were 15.2 N (11.4-19.0 N), 15.8 N (13.6-18.1 N), 15.6 N (13.1-18.4 N), 16.6 N (13.7-19.5 N), and 22.3 N (16.6-27.9 N), respectively. In the same respective order, the break force and 95% CI were 25.9 N (21.9-29.8 N), 26.5 N (23.2-29.7 N), 31.1 N (26.1-36.1 N), 35.6 N (28.2-43.1 N), and 51.8 N (62.5-41.0), respectively. The Fisher least significant difference demonstrated significant differences between the control group and all experimental groups for both gap force and break force. CONCLUSIONS: Obliquity of tendon laceration affects the core suture strength when compared with a transverse cut. Flexor tendons cut at 90° demonstrated a higher overall gap force and breaking strength that were statistically significant when compared with all obliquely cut groups. These findings should be considered when repairing and starting postoperative therapy for obliquely cut tendons.

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Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.

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Introduction Hand and digit replantations can be complicated by vascular insufficiency necessitating revision of the original replantation. To date, few studies have evaluated outcomes in secondary revascularizations following replantation. Therefore, the objective of this study was to evaluate the incidence, etiology, and survival rates following secondary revascularization after hand and digit replantations. Materials and Methods A literature search was performed on NCBI for studies documenting secondary revascularization procedures following hand and digit replant. Studies were evaluated for the etiology of vascular failure, frequency of secondary revascularization, and survival rates following intervention. Statistical analysis was conducted across the pooled dataset. Results A total of 16 studies including 1,192 amputations were analyzed. We found that 16.9% (201/1,192) of replants were complicated by vascular compromise. The frequency of vascular compromise was not statistically different between arterial and venous etiologies. The survival rate following secondary revascularization was 55.6%, with no significant difference between the arterial and venous groups. Secondary arterial revascularization was often treated with arterial revision (nine of nine studies) and/or with vein grafting (two of nine studies). Secondary revascularization for venous insufficiency resulted in different survival rates for nonsurgical modalities (58%) versus vein revision (37.5%) versus vein grafting (100%). Conclusion Survival rates following secondary revascularization are lower; however, they may be improved using vein grafts following venous insufficiency. These data can be used to better understand the etiology of replant failure and guide decision-making.

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Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.

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BACKGROUND: Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition. RESULTS: A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods. CONCLUSION: The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.

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Mixed reality, a blending of the physical and digital worlds, can enhance the surgical experience, leading to greater precision, efficiency, and improved outcomes. Various studies across different disciplines have reported encouraging results using mixed reality technologies, such as augmented and virtual reality. To provide a better understanding of the applications and limitations of this technology in plastic surgery, we performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The initial query of the National Center for Biotechnology Information database yielded 2544 results, and only 46 articles met our inclusion criteria. The majority of studies were in the field of craniofacial surgery, and uses of mixed reality included preoperative planning, intraoperative guides, and education of surgical trainees. A deeper understanding of mixed reality technologies may promote its integration and also help inspire new and creative applications in healthcare.

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Introduction Patient satisfaction is an important clinical marker for hand/upper extremity patients. Few studies have investigated the predictors of patient satisfaction in the clinic setting. Our objective was to analyze patient satisfaction surveys to explore factors that influence patient satisfaction. Materials and Methods We conducted a retrospective analysis assessing patient satisfaction in the hand/upper extremity clinics at our university medical center between 2012 and 2018. Patient satisfaction was assessed via Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Patient demographics, satisfaction scores, and clinic experience questionnaire responses were evaluated. Statistical analysis was conducted to identify significant trends. Results Between 2012 and 2018, 102 surveys were completed. Scores ranged from 5 to 10 with an average provider rating of 9.56. We found six factors significantly influenced patient satisfaction: adequate time was spent with the provider, provider showed respect, patient was seen by provider within 15 minutes of appointment time, provider listened sufficiently, patient received understandable medical instructions, and understandable medical explanations ( p < 0.05). Conclusion Achieving patient satisfaction is an important clinical marker in hand/upper extremity clinics. Patient satisfaction has defined predictors wherein various clinical factors can influence patient satisfaction and willingness to refer their provider to other patients.

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Diabetes mellitus (DM) is a chronic disease that results in a variety of systemic complications. Recently, stem cell-based therapies have been proposed as potential modalities to manage DM related complications. Mesenchymal stem cell (MSC) based therapies are often considered as an ideal stem cell-based treatment for DM management due to their immunosuppressive characteristics, anti-inflammatory properties and differentiation potential. While MSCs show tremendous promise, the underlying functional deficits of MSCs in DM patients is not well understood. Using the MEDLINE database to define these functional deficits, our search yielded 1826 articles of which 33 met our inclusion criteria. This allowed us to review the topic and illuminate four major molecular categories by which MSCs are compromised in both Type 1 DM and Type II DM models which include: (1) changes in angiogenesis/vasculogenesis, (2) altered pro-inflammatory cytokine secretion, (3) increased oxidative stress markers and (4) impaired cellular differentiation and decreased proliferation. Knowledge of the deficits in MSC function will allow us to more clearly assess the efficacy of potential biologic therapies for reversing these dysfunctions when treating the complications of diabetic disease.

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BACKGROUND: Early evaluation and appropriate management of pediatric scaphoid fractures are necessary to avoid complications. To date, current management of pediatric fractures varies among providers. The objective of this study was to compare clinical outcomes following different treatment modalities. METHODS: A PubMed literature search identified studies involving acute scaphoid fractures in children. Studies were evaluated for treatment provided and their respective effects on union rate, wrist range of motion, and wrist pain. Data were pooled across studies, and quantitative statistical analysis was conducted to compare outcomes. RESULTS: Seventeen studies representing 812 acute pediatric scaphoid fractures were included in the current analysis. We found 93.5% of scaphoid fractures were treated with cast immobilization vs 6.5% treated surgically as 13 of 17 authors treated all fractures with immobilization vs 4 of 17 studies who offered surgical intervention. We found pediatric scaphoid fractures had excellent bone union rates (96.2%) with no difference between the cast immobilization and surgery groups ( P value NS). Long- and short-arm thumb spica immobilization protocols were commonly employed; however, we found no difference in the rates of union ( P value NS). At follow-up, 99.0% of patients treated nonoperatively had normal wrist range of motion and 96.8% were pain free. CONCLUSIONS: Pediatric scaphoid fractures have excellent outcomes. Nonoperative treatment results in a high rate of union with few posttreatment wrist symptoms. Nonsurgical treatment represents an adequate treatment modality in a majority of acute pediatric scaphoid fractures, wherein the role for surgery needs to be better defined.

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BACKGROUND: Poly-trauma patients often sustain complex head/neck injuries requiring prolonged hospitalizations and multiple operations. Few studies have evaluated the associated injury patterns and risk factors for poor clinical outcomes. METHODS: Consecutive poly-trauma patients with operative maxillofacial fractures treated at a level 1 trauma medical center between 1995 and 2013 were evaluated. Concomitant head/neck injuries to identify potential injury patterns were numerated. Lastly, a multivariate analysis was performed to determine independent risk factors for complications during the acute hospitalization period. RESULTS: Totally, 232 poly-trauma patients presented with operative maxillofacial fractures, while 38.8% of patients had a secondary maxillofacial fracture, 16.4% had intracranial hemorrhage, 23.7% had skull fractures, and 12.1% had spinal fractures. The rate of complication during admission was 28.3%. Multivariate analysis revealed advanced patient age and increased number of operations to predict the rate of complication. Patients requiring more than one operation had a 1.8-fold increase in complication rate (p<0.01) and older patients had a 4.5% increase in complication rate (p<0.05) for every year of increased age. CONCLUSION: Poly-trauma patients have a high incidence of secondary maxillofacial fractures, concomitant head/neck injury, and inpatient complication rate. Knowledge of associated injury patterns can help increased awareness and can guide physician decision-making to avoid missed/delayed injuries.

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Introduction Microsurgical replantation following digital amputation has variable success rates. Sociodemographic factors and surgery-related variables have been shown to influence survival rates; however, few studies have evaluated these data systematically across a combined dataset. Therefore, the objective of this study was to analyze the current literature to identify the predictors of replant survival. Materials and Methods A literature review was performed using the PubMed/Medline database focused on complete digit amputation/replantation studies. Studies were evaluated for patient and surgery-related variables and their respective effects on survival. Statistical analysis was conducted to identify predictors of survival and derive pooled estimates from the combined dataset. Results Thirty-two studies representing more than 6,000 digit amputation/replantation cases met inclusion/exclusion criteria. Statistical analysis revealed the number of venous anastomosis (0 vs. 1 vs. 2), the number of arterial anastomosis (0 vs. 1 vs. 2), and the mechanism of injury (sharp cut versus blunt cut versus avulsion versus crush) to influence replant survival ( p < 0.05). The authors failed to find a significant association between survival and the following variables: age, sex, zone of injury, digit number, tobacco use, ischemia time, method of preservation, and use of vein graft. Conclusion Patient- and surgery-related variables affect digit survival following replantation. The etiology of injury can help risk-stratify patients and assist in an informed decision making process, whereas surgery-related factors can guide surgeon practice to improve clinical outcomes following replantation.

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Adipogenesis is a complex process whereby the multipotent adipose-derived stem cell is converted to a preadipocyte before terminal differentiation into the mature adipocyte. Preadipocytes are present throughout adult life, exhibit adipose fat depot specificity, and differentiate and proliferate from distinct progenitor cells. The mechanisms that promote preadipocyte commitment and maturation involve numerous protein factor regulators, epigenetic factors, and miRNAs. Detailed characterization of this process is currently an area of intense research and understanding the roles of preadipocytes in tissue plasticity may provide insight into novel approaches for tissue engineering, regenerative medicine and treating a host of obesity-related conditions. In the current study, we analyzed the current literature and present a review of the characteristics of transitioning adipocytes and detail how local microenvironments influence their progression towards terminal differentiation and maturation. Specifically, we detail the characterization of preadipocyte via surface markers, examine the signaling cascades and regulation behind adipogenesis and cell maturation, and survey their role in tissue plasticity and health and disease.

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The pathogenesis of neurofibromas is poorly understood outside of neurofibromatosis (NF). The BRAF proto-oncogene has been implicated in malignant peripheral nerve sheath tumors (PNSTs), however its role in neurofibromas has not been described. In this study, we identify a BRAF mutation in a 61-year old non-NF patient with a history of sporadic and recurrent neurofibromas localized to the right upper extremity. Despite repeat resections to establish local control, he developed median nerve neuropathy secondary to a 13×4cm plexiform neurofibroma. Genetic sequencing of the neurofibroma revealed the expression of a novel BRAF L597Q mutation. This study is the first to describe the BRAF L597Q mutation in PNSTs and the first to implicate a BRAF mutation in neurofibroma biology. We hypothesize that BRAF mutations may identify a molecularly-distinct subset of recurrent neurofibromas and may provide potential for targeted therapeutics.

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BACKGROUND: Post-mastectomy breast reconstruction is commonly performed in the United States with numerous options available to patients and providers. This study evaluated patient race and provider in prediction of patient satisfaction following post-mastectomy breast reconstruction. METHODS: The patient satisfaction for women who underwent post mastectomy breast reconstruction at University of California, Irvine Medical Center was evaluated between 2012 and 2014, randomly using Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Patient demographics and surgery related variables including type of reconstruction received were determined. RESULTS: Between 2012 and 2014, ninety breast reconstruction patients completed a HCAHPS satisfaction survey. Average satisfaction score was 9.67/10. Multivariate linear regression analyses revealed that 34% of the variability in satisfaction scores was accounted for by the variables included in our statistical model. Analyses revealed race/ethnicity and provider to be independent predictors of satisfaction (p<0.05). Satisfaction scores ranged from 6-10 and varied by 11.7% across different providers and 8.9% across different races. The following variables were included, but did not influence patient satisfaction: type, timing, or laterality of reconstruction, presence of post-operative complication, body mass index (BMI), age, presence of comorbidity, and insurance type. CONCLUSION: Achieving patient satisfaction is an important outcome of breast reconstruction. This study is one of the first to identify provider and race/ethnicity as predictors of patient satisfaction following breast reconstruction. The information provided here can help inform providers and improve satisfaction for patients undergoing breast reconstruction.

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BACKGROUND: Combined procedures involving elective breast surgery at the time of abdominoplasty are frequently performed procedures in aesthetic plastic surgery. While found to be safe outpatient procedures, many surgeons elect to perform combined abdominoplasty/breast surgery as inpatient surgery. This study was performed to explore the practice of performing the combined procedure as an inpatient in the United States. METHODS: The Nationwide Inpatient Sample database was evaluated using ICD-9CM procedural codes to identify hospitalizations where patients underwent abdominoplasty combined with breast surgery. We trended the frequency of this combined procedure, and evaluated the rate of acute post-operative complications, length of inpatient hospitalization, and total hospital charges. RESULTS: Between 2004 and 2011, 29,235 combined abdominoplasty/breast procedures were performed as inpatient in United States. The rate of major post-operative complications in the acute hospitalization period was 1.12% and included CVA (0.02%), respiratory failure (0.6%), pneumonia (0.3%), VTE (0.1%), and myocardial infarction (0.1%). Hospitalization averaged 1.8 days and resulted in $31,177 of hospital charges. The demographics of the combined procedure transitioned as i) frequency of inpatient surgeries decreased, ii) percent of patients >50 yr increased, and iii) hospital charges increased from 2004 to 2011. CONCLUSION: A significant number of surgeons are performing combined abdominoplasty and elective breast surgery as inpatient procedures in United States. The combined surgery is safe but is associated with small risk of major post-operative complications. A short inpatient hospitalization may be beneficial for high-risk patients interested in combined procedures, but must be analyzed against the rising costs of inpatient surgery.

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PURPOSE: The human c2orf40 gene encodes a candidate tumor suppressor called Esophageal Cancer-Related Gene-4 (ECRG4) that is a cytokine-like epigenetically-regulated protein that is characteristically downregulated in cancer, injury, inflammation, and infection. Here, we asked whether ECRG4 gene expression is detectable in lung epithelial cells and if its expression changes with inflammation, infection, and/or protective preconditioning. MATERIALS AND METHODS: We used immunoblotting, PCR, and quantitative PCR to measure ECRG4 and either inhalation anesthesia preconditioning, lipopolysaccharide injection, or laparotomy to modulate lung inflammation. RESULTS: Immunoblotting establishes the presence of the full-length 14 kDa ECRG4 peptide in mouse lung. Immunohistochemistry localizes ECRG4 to type l alveolar epithelial cells. Basal ECRG4 mRNA is greater than TNF-α, IL-1ß, and IL-6 but following inflammatory lung injury, TNF-α, IL-1ß, IL-6, and IL-10 are upregulated while ECRG4 gene expression is decreased. Similar findings are observed after an intravenous administration of lipopolysaccharide. In contrast, lung preconditioning with isoflurane anesthesia increases lung ECRG4 gene expression. Over-expression of ECRG4 in human lung epithelial cells in vitro decreases cell proliferation implying that a loss of ECRG4 in vivo would be permissive to cell growth. CONCLUSIONS: This study supports the hypothesis that ECRG4 acts as a sentinel growth inhibitor in lung alveolar epithelial cells. Its downregulation by injury, infection, and inflammation and upregulation by preconditioning supports a role for ECRG4 in regulating the alveolar epithelium response to injury and inflammation. By extension, the findings support a functional consequence to its inhibition by promoter hypermethylation (i.e. lung cancer) and suggest potential benefits to its upregulation.

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The development of autologous fat grafting to augment or reconstruct tissue defects has become an increasingly popular modality among plastic surgeons. Despite its popularity, a standardized fat grafting protocol has yet to be developed. Great variations exist with regard to almost all the technical features, yielding a reported fat graft survivability that ranges from 40% to 80%. Recent bench approaches have been proposed to improve the long-term viability of fat grafts: although promising results have been shown, empirical evidence has yet to prove the superiority of one particular method. Nevertheless, currently available literature still provides some evidence for optimal results in differing clinical scenarios, in the wait of validating and ultimate studies.The issues of enriched fat grafting techniques and variations in harvesting and delivery in the background of US regulatory constraints demand alterations and variations in techniques. These only complicate the process of validation of any single technique. However, recent studies have brought us closer to making informed decisions on technical choices in lipotransfer. These are elaborated on in this review.

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BACKGROUND: Breast reconstruction improves the quality of life for mastectomy patients but is underutilized in the United States. This study investigated reconstruction rates for a dual-trained oncologic plastic surgeon to explore how provider-based factors influence reconstruction. METHODS: We evaluated consecutive mastectomy patients treated at the University of California, San Diego Medical Center between 2009 and 2012. We identified mastectomy patients based on Current Procedural Terminology codes and evaluated them for patient- and disease-specific variables. We evaluated reconstruction rates for the traditional team model of collaborating plastic and oncologic surgeons versus a single surgeon, dual trained in surgical breast oncology and plastic surgery. A multivariate regression analysis was then used to identify the significant predictors of reconstruction. RESULTS: Mastectomy was performed in 344 patients. The surgeon group was a significant predictor of postmastectomy reconstruction (p < 0.05). The traditional team of oncologic and plastic surgeons reconstructed 93 (63.3 %) of 147 mastectomy patients, whereas the single dual-trained surgeon reconstructed 140 (71.1 %) of 197 mastectomy patients. Race and insurance status did not influence the receipt of reconstruction in our single-surgeon model, however, patients of older age [odds ratio (OR) 0.93, confidence interval (CI) 0.89-0.98, p < 0.01], higher body mass index (OR 0.89, CI 0.82-0.97, p < 0.01), or more advanced disease (p < 0.01) were less likely to undergo reconstruction. CONCLUSIONS: A single dual-trained surgeon for breast care influences reconstruction rates. A dual-trained surgeon increases the likelihood of reconstruction and obtains rates higher than previously reported. This may reflect the comprehensive care provided by a multidisciplinary-trained professional. A single surgeon providing care in oncology and reconstruction represents a comprehensive approach to breast care and demonstrates a relationship between provider practice and breast reconstruction.

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The Esophageal cancer-related gene-4 (Ecrg4) is a candidate tumor suppressor gene whose secreted protein product has been implicated in the development and progression of epithelial cancers, neuroprogenitor cell activation after central nervous system injury, cell senescence in neurodegeneration, and the survival of hematopoietic stem cells. Here, we investigated the temporal and spatial localization of Ecrg4 expression in healthy and injured mouse skin, and evaluated the biological activity of Ecrg4 using viral-mediated gene delivery in cutaneous wound healing models. Using in situ hybridization and immunohistochemistry, we found both Ecrg4 mRNA and its protein product localized to the epidermis, dermis, and hair follicles of healthy mouse skin. Upon cutaneous injury, Ecrg4 redistributed to the wound margins where gene microarray and quantitative RT-PCR showed an increased gene expression 5-10 days post-injury as a late phase injury response gene. Ecrg4 over-expression inhibited the directional migration of fibroblasts in modified Boyden chambers in vitro, but had no effect on rates of fibroblast proliferation. Ecrg4 over-expression in vivo at the wound margins delayed the rate of wound closure at 1 and 2 days after full-thickness punch injury. These findings point to the candidate tumor suppressor gene Ecrg4 as a novel, biologically active, constituent of skin and skin injury. The possibility that Ecrg4 serves as a wound termination factor during wound resolution is discussed.

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