Background: Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone. Methods: A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5-year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment. Results: Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not. Conclusions: Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The ability to perform nonsurgical facial rejuvenation procedures is a core competency requirement for plastic surgery residents. However, limited data exist on training models to achieve competency in nonsurgical facial rejuvenation and on outcomes of these procedures performed by residents. The purpose here is to evaluate patient-reported outcomes and safety of nonsurgical facial rejuvenation procedures performed by plastic surgery residents. Methods We prospectively enrolled 50 patients undergoing neuromodulator and/or soft-tissue filler injections in a resident cosmetic clinic between April and August 2016. Patients completed FACE-Q modules pre-procedure, and at 1 week and 1 month post-procedure. Paired t-tests were used to calculate statistical significance of changes between pre- and post-procedure scores. Effect sizes were calculated to assess clinical improvement from pre- to post-procedure. The magnitude of change was interpreted using Cohen’s arbitrary criteria (small 0.20, moderate 0.50, large 0.80). Results Forty-five patients completed the study. Patients experienced significant improvements (p < 0.001) in all FACE-Q domains, including aging appearance appraisal (improved from 49.7 ± 29.4 to 70.1 ± 21.6, effect size 0.79), psychological well-being (44.0 ± 14.6–78.6 ± 20.7, effect size 1.93), social functioning (48.6 ± 16.6–75.5 ± 21.7, effect size 1.20), and satisfaction with facial appearance (50.1 ± 13.7–66.2 ± 19.7, effect size 0.95). At 1 month, overall satisfaction with outcome and decision were 75.8 ± 20.7 and 81.1 ± 20.4, respectively. No patients experienced complications. Conclusions Nonsurgical facial rejuvenation procedures performed by residents can improve patients’ quality of life and provide high satisfaction without compromising safety. Level of Evidence IV This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Background/Objectives: Many patients evaluated by shoulder specialists suffer from intractable pain, neuropathy, and weakness. The pectoralis minor (PM) remains the only scapula muscle to receive lower trunk (C8-T1) input. We propose a novel syndrome: the Human Disharmony Loop. This model portrays how this unique PM innervation causes scapular dyskinesia, which deranges the anatomy of the upper limb girdle and produces a refractory symptom complex of pain, neuropathy, and weakness. We hypothesize that certain patients with historically intractable symptoms of the upper limb girdle may benefit from PM tenotomy. Methods: Ten patients of diverse etiologies presented with a similar constellation of complaints. The patients included a female athlete, a female with macromastia, a male bodybuilder, and patients with post-radiation breast cancer, post-operative shoulder arthroplasty, interscalene block injury, cervical spine disease, persistent impingement after rotator cuff repair, direct traction injury, and occupational disorder. All patients exhibited coracoid tenderness, scapula protraction with internal rotation and anterior tilt, and pain involving the neck, shoulder, and upper back. The patients demonstrated varying degrees of arm neuropathy, subacromial impingement, and occipital headaches. The patients failed all prior treatments by multiple subspecialists, including surgery. Each patient underwent isolated open PM tenotomy. Results: In all ten patients, PM tenotomy substantially reduced shoulder, upper back, and neck pain, cleared concomitant neuropathy, restored full motion, and eradicated occipital headaches. The response to surgery was rapid, dramatic, and durable. Conclusions: The unique asymmetric neurologic innervation to the sole ventral stabilizer of the scapula, the pectoralis minor, predisposes the human shoulder to neurologic and musculoskeletal imbalance. This produces the Human Disharmony Loop: a clinical syndrome spanning from the neck to the fingertips, with chronic pain, neuropathy, and weakness. These challenging patients may benefit dramatically from isolated PM tenotomy.

Background/Objectives: Patients commonly present with a mix of intractable shoulder pain, persistent impingement/loss of shoulder motion, neck pain, headaches, and distal neuropathy. These patients are notoriously resistant to surgical and non-surgical treatments. Previously we proposed the Human Disharmony Loop (HDL) as a model that anatomically explains these symptoms and diagnostically predicts successful response to surgical intervention. The purpose of this study is to validate positive surgical treatment outcomes in patients diagnosed in the HDL via retrospective chart review. We hypothesized that pectoralis minor release would reliably decrease pain and occipital headaches and increase shoulder motion for patients who met diagnostic criteria for the HDL. Methods: Patients diagnosed with the HDL and treated with pectoralis minor release at two separate institutions with at least 6-month follow-up were included. Diagnosis was based on explicit anatomic and symptomatic criteria: coracoid tenderness, scapular protraction, and at least one end symptom. Neuropathy was tested using the scratch-collapse test. Outcomes included pain scores, clinical neuropathic lesions, rotator cuff impingement signs, shoulder range of motion, and complications. Results: 115 patients were included. Average age was 48. 37% were male. 89% of patients who received a preoperative subcoracoid injection reported a significant decrease in presenting symptoms. 6 months after PM release, median VAS pain scores decreased from 8 to 2. Occipital headaches decreased from 66% to 6%. Rotator cuff impingement decreased from 87% to 10%. Median shoulder abduction increased from 90 to 180 degrees. Neuropathy decreased at the following locations: scalenes 57–2%, suprascapular 51–0%, quadrilateral 81–5%, radial 60–11%, cubital 31–25%, carpal 53–25%. 25% of patients required secondary distal neurolysis. Complications remained low at 3% (3 seroma, 1 wound dehiscence). Conclusions: Patients diagnosed with the Human Disharmony Loop exhibit a dramatic clinical improvement following pectoralis minor release. A medial coracoid pectoralis minor block injection can aid in diagnosis but does not rule-out the syndrome. Patients showed significant reductions in shoulder pain, headaches, concomitant neuropathic lesions and improved shoulder range of motion. Patients should be counseled that some may need secondary neurolysis for residual neuropathy.

Background: Subacromial impingement or pain syndrome (SAPS) is the most common diagnosis for chronic shoulder pain. Current surgeries do not reduce long-term pain, suggesting they miss the root etiology. Previously, we described the Human Disharmony Loop (HDL), where the unique lower trunk innervation to the pectoralis minor (PM) causes scapular dyskinesis and deforms its connections, including tugging the acromion down and impinging the subacromial structures. We hypothesize that SAPS patients who meet HDL criteria would benefit significantly from PM tenotomy with infraclavicular brachial plexus neurolysis (PM + ICN) alone. Methods: SAPS patients who met HDL diagnostic criteria were treated with PM + ICN, with secondary distal neurolysis if needed. Outcomes included pain and shoulder abduction ROM. Six-month follow-up minimum was required. Results: N = 140 patients were included. Median age was 49. Prior surgeries included 27% subacromial decompression/acromioplasty, 21% rotator cuff repair, 16% biceps tenodesis, 4% SLAP repair, 2% labral repair, 7% distal clavicle resection, 10% reverse total shoulder arthroplasty (rTSA), 1% rib resection with scalenectomy, 16% cervical spine fusion, 28% distal neurolysis. Median pain decreased from 8 to 2 and median shoulder ROM increased from 90 to 180 degrees. Positive impingement signs on exam decreased from 100% to 11%. (p < 0.01) Conclusions: In a large series of SAPS patients, evaluation and treatment for the HDL significantly reduced pain and restored motion. These findings suggest that in many patients SAPS may be a subset of the HDL: the ventral PM disturbing the scapula constitutes the anatomic basis and optimal surgical target behind SAPS.

Background/Objectives: Many patients evaluated by shoulder specialists suffer from intractable pain, neuropathy, and weakness. The pectoralis minor (PM) remains the only scapula muscle to receive lower trunk (C8-T1) input. We propose a novel, unifying musculoskeletal and neurologic syndrome: the Human Disharmony Loop. This model portrays how this unique PM innervation causes scapular dyskinesia which deranges the anatomy of the upper limb girdle and produces a refractory symptom complex of pain, neuropathy, and weakness. Methods: Ten patients of diverse etiologies presented with a similar constellation of complaints. Patients included: female athlete, female with macromastia, male bodybuilder, post-radiation breast cancer, postoperative shoulder arthroplasty, interscalene block injury, cervical spine disease, persistent impingement after rotator cuff repair, direct traction injury, and occupational disorder. All patients exhibited coracoid tenderness, scapula protraction with internal rotation and anterior tilt, and pain involving the neck, shoulder, and upper back. Patients demonstrated varying degrees of arm neuropathy, subacromial impingement, occipital headaches. Patients failed all prior treatments by multiple subspecialists including surgery. Each patient underwent isolated open PM tenotomy. Results: PM tenotomy completely resolved presenting signs and symptoms in all patients. This included elimination of shoulder, upper back, and neck pain, clearance of concomitant neuropathy, resolution of rotator cuff impingement, restoration of full motion, and eradication of headaches. Response to surgery was rapid, dramatic, and durable. Conclusions: The unique asymmetric neurologic innervation to the sole ventral stabilizer of the scapula, the pectoralis minor, predisposes the human shoulder to neurologic and musculoskeletal imbalance. This produces the Human Disharmony Loop: a clinical syndrome spanning the neck to the fingertips of chronic pain, neuropathy, and weakness. These challenging patients may benefit dramatically from isolated PM tenotomy.