Plastic and reconstructive surgery最新文献

Background: Brachial plexus birth injuries (BPBI) occur as a result of a difficult delivery. External rotation of shoulder (ER) is usually one of the last movements which may recover. There is no consensus about the predicting factors for spontaneous recovery or the optimal timing for surgical treatment of ER in BPBI patients. The aim of our retrospective study was to describe spontaneous recovery of active ER and evaluate predicting factors for the recovery.

Methods: We screened 562 patients and identified a consecutive cohort of 103 BPBI patients, who had no active ER at the age of 3 months. We systematically collected clinical data on recovery. In addition, we assessed whether early recovery of elbow flexion, shoulder abduction or Narakas grade at 1 month predicts ER recovery.

Results: Fifty-two (51%) patients spontaneously recovered ER, 44% of whom were recovered by the age of 1 year, 83% by 1.5 years, 92% by 2 years and 98% by 3 years. A breakpoint in the slope of the curve showing proportion of recovered patients occurred at 2 years of age. Recovery of active ER was significantly associated with early elbow flexion and Narakas grade at 1 month, but not with early active shoulder abduction.

Conclusions: Most spontaneous recovery of ER in patients with BPBI occurs until 2 years of age, which thus can be considered a meaningful follow-up period for spontaneous recovery of ER. This information should be considered when making decision about peripheral nerve transfer surgery to improve ER in BPBI.

Background: The risk/benefit ratio of operating on the cleft nasal deformity in the period of mixed dentition remains debated. This study characterizes our 18-year experience with intermediate cleft rhinoplasties to add data and nuance to the discussion.

Methods: We performed a retrospective cohort study of patients who underwent intermediate cleft rhinoplasty from 2006 to 2023. Demographic information and operative details were collected. Primary outcomes were operative complications and need for subsequent rhinoplasty.

Results: Three-hundred and forty-two patients undergoing 372 intermediate rhinoplasties were included: 150 (40.3%) with no graft/implant, 165 (44.4%) with iliac crest cartilage graft, 36 (9.7%) with ear cartilage, 19 (5.1%) with a resorbable plate, and 3 (0.8%) with nasal cartilage. Use of iliac crest graft predicted fewer subsequent rhinoplasties independent of age at surgery, age at most recent follow-up, sex, race, syndromic status, cleft severity, intranasal stenting duration, and surgeon (β=-0.234, p=0.012). Employment of a V-Y chondromucosal flap in the unilateral cleft lip group (β=-0.401, p=0.002) and placement of a columellar strut graft in the bilateral cleft lip group (β=-0.450, p=0.028) predicted fewer subsequent rhinoplasties. The proportion of rhinoplasties utilizing iliac crest grafts increased over time (r(372)=0.806, p<0.001). Most (55.0%) patients with follow-up beyond age 18 (n=60) did not require subsequent rhinoplasty.

Conclusions: Iliac crest cartilage grafting as a columellar strut in bilateral clefts and a chondromucosal V-Y advancement in unilateral clefts were associated with a decreased need for future rhinoplasty. Further work is needed to understand the risk/benefit ratio, surgical burden, and patient-reported outcomes of intermediate rhinoplasty.

Background: There is a lack of studies exploring factors influencing synkinesis severity. This study aims to identify factors that may contribute to variations in severity of facial synkinesis.

Methods: Patients with a diagnosis of facial synkinesis presenting between 2009 and 2024 were reviewed. The synkinesis score of the eFACE Facial Nerve Clinician-Graded Scale was analyzed for associations with patient characteristics and facial palsy history using univariable and multivariable analysis.

Results: Two-hundred-forty-nine synkinesis patients were included in the study. The etiology of facial palsy was infectious or idiopathic in 185 patients (74%), tumor resection in 40 patients (16%), trauma in 17 patients (7%), and compression of the facial nerve by a benign tumor in seven patients (3%). Factors independently associated with more severe synkinesis scores included age of facial palsy onset over 50 years (-7.4, 95% CI, [-10.9, -3.9]; p < 0.001), diabetes (-8.6, 95% CI, [-14.9, -2.3]; p = 0.007), smoking (-4.9; 95% CI, [-8.0, -1.8]; p = 0.003), and intratemporal facial nerve injury (-19.4; 95% CI, [-27.8, -10.8]; p < 0.001). Other variables including sex, race, hypertension, and etiology were not found to be independently associated with synkinesis severity.

Conclusions: Older age at facial palsy onset, diabetes, smoking, and intratemporal facial nerve injury were found to be independently associated with more severe synkinesis. These findings are novel and may aid in prognostication and treatment selection.

Background: Mandibular distraction osteogenesis (MDO) and pre-epiglottic baton plates (PEBP) are both effective for early management of upper airway obstruction (UAO) in infants with Robin sequence (RS), but have not been directly compared. The purpose of this study was to compare early airway, feeding and growth outcomes between these treatments.

Methods: This is a bicentric retrospective cohort study from 2015-2021 including infants with RS treated with MDO or PEBP before 6 months-of-age with pre- and post-treatment sleep studies and follow-up at least through age 1-year. The primary outcome was immediate post-intervention UAO, measured as obstructive apnea-hypopnea index (oAHI) or obstructive apnea index (oAI), as available. Latest follow-up sleep studies, feeding and growth characteristics were also assessed.

Results: 114 subjects were included: MDO, n=31 and PEBP, n=83. Pre-treatment UAO was similar between groups (p=0.61). PEBP was initiated at a younger age (median [IQR] 31 [14,53] vs. 41 [28,84] days-of-life, p<0.05). Significant reduction of oAHI/oAI was achieved in both groups, but greater with MDO (98%) compared to PEBP (94%, p<0.05). PEBP demonstrated better early feeding and growth outcomes compared to MDO, with fewer surgical feeding tubes (p<0.001) and more rapid early growth (p=0.038). When stratified by pre-intervention UAO, infants starting with moderate UAO experienced similar airway outcomes with both treatments (p=0.11), while those with severe UAO had greater resolution with MDO (p<0.001).

Conclusion: Both treatments effectively relieve moderate UAO in infants with RS, but MDO is more effective for infants with severe respiratory compromise.

Background: In ulnar neuropathy at the elbow, weakness is classically a sign of severe disease. Weakness is associated with motor axonal loss as measured by decreased distal compound muscle action potential (CMAP) amplitude. Conduction block, a demyelinating phenomenon that recovers readily, can also cause weakness, creating ambiguity for the treating clinician.

Methods: This cross-sectional study evaluated baseline blinded data collected from 2020-2023 from the Surgery of the Ulnar Nerve randomized controlled trial comparing in-situ decompression versus transposition procedures. Adult patients underwent electrodiagnostic testing, clinical motor and sensory testing, and completed the Michigan Hand Questionnaire and Carpal Tunnel Questionnaire.

Results: 177 patients were categorized into 3 distinct groups based on normal distal CMAP amplitudes (77 patients), presence of conduction block with or without distal CMAP amplitude loss (37 patients), or pure axonal loss with distal CMAP amplitude loss in the absence of conduction block (63 patients). Compared to the normal group, patients with conduction block had significantly decreased pinch strength and worse function domain scores on the Michigan Hand Questionnaire and Carpal Tunnel Questionnaire, but shorter duration of disease. Patients with pure axonal loss had decreased pinch strength, worse 2-point discrimination, and worse overall, function and aesthetics domain scores on the Michigan Hand Questionnaire. There was a significant interaction between the effects of conduction block and distal CMAP amplitude on pinch strength, indicating that higher degrees of conduction block resulted in more pronounced loss of pinch strength in patients with relatively preserved distal CMAP amplitude.

Conclusions: Our findings support the paradigm that ulnar neuropathy at the elbow presenting with conduction block represents a distinct and intermediate pathophysiology, distinguished by quicker onset with less advanced neurological deficits.

Level of evidence: Prognostic Level II.

Background: Microtia with constricted ear features represents a challenging congenital deformity characterized by the variable shape and large volume of the remnant cartilage and skin involved. This study aims to evaluate the efficacy and safety of a method using helix costal cartilage scaffold and postauricular flap advancement for the correction.

Methods: This retrospective study analyzed the clinical and postoperative data of 121 patients diagnosed with microtia and constricted ear features, treated at our institution between January 2020 and January 2023. All patients underwent helix reconstruction using the eighth or ninth costal cartilage combined with postauricular flap advancement. Outcomes were assessed based on the incidence of postoperative complications and auricular aesthetic scores. The aesthetic evaluation of the reshaped auricle was based on a four-point Likert scale (i.e. 1 = poor, 2 = fair, 3 = good, 4 = excellent).

Results: The postoperative follow-up period ranged from 12 months to 3 years (mean 18.5 months). All patients achieved successful helix expansion, with reconstructed ears showing improved symmetry and shape comparable to the contralateral normal ears. The average aesthetic score was 3.4 out of 4. Complications included suture exposure in 8.3% of cases and cartilage protrusion in 4.1%, both managed without significant issues. There were no instances of skin necrosis, costal cartilage exposure, or infection.

Conclusions: The combination of helix costal cartilage scaffold and postauricular advancing flap offers a reliable and effective method for correcting microtia with constricted ear features, providing satisfactory aesthetic outcomes with minimal complications.

Background: This study updates the authors' institutional experience with modified Furlow palatoplasty, evaluating speech outcomes and incidence of secondary speech surgery throughout development and at skeletal maturity.

Methods: Nonsyndromic patients undergoing primary modified Furlow palatoplasty between 1985 and 2005 with postoperative speech evaluations were reviewed retrospectively. Secondary speech surgery and Pittsburgh Weighted Speech Scale (PWSS) scores before secondary speech or orthognathic operations were assessed in the groups aged 5 to 7 years, 8 to 11 years, 12 to 14 years, and older than 15 years and analyzed by Veau cleft type.

Results: A total of 551 patients with 895 total speech assessments were analyzed. Of 364 patients followed up to age 15 years or older, 19.8% underwent secondary speech surgery. Speech assessment of patients aged 15 years or older without prior secondary speech surgery showed competent velopharyngeal mechanisms in 77% of patients. PWSS nasal emission scores were worse in the 5- to 7-year age range ( P = 0.02), whereas resonance scores remained stable throughout development ( P = 0.2). Patients with Veau type I or II clefts had worse overall PWSS classifications in the groups aged 5 to 7 years and 8 to 11 years ( P = 0.01 and P = 0.03), with greater odds of secondary speech surgery relative to those with Veau type III (OR, 2.9; P < 0.001) or IV clefts (OR, 3.6; P = 0.001).

Conclusions: Most patients undergoing primary modified Furlow palatoplasty do not require secondary speech surgery and achieve socially acceptable speech at skeletal maturity. However, Veau type I and II clefts are associated with increased risk for early velopharyngeal dysfunction and secondary speech surgery. The incidence of secondary speech surgery was 19.8%, an increase from our previously reported rate of 8%.

Clinical question/level of evidence: Therapeutic, III.

Background: Many studies recommend nonsurgical auricular correction during the early postnatal period, when cartilage plasticity is high; however, many patients are not eligible for the procedure. This study compared different timings of nonsurgical auricular correction to investigate benefit after the optimal period for correction.

Methods: In this prospective study, 53 ears from 35 patients with congenital auricular anomaly were assigned to 2 groups according to age at correction: the early group, with correction within 2 weeks of birth, and the late group, with correction 8 weeks after birth. Aesthetic outcomes, caregiver satisfaction, detachment rates, and mean device-wearing periods were compared.

Results: Thirty-one ears from 20 patients constituted the early group, and 18 ears from 12 patients constituted the late group. Mean time to treatment after birth was 9.09 days in the early group and 134.7 days in the late group. In the early group, detachment occurred in 4 of 31 ears (12.9%), and in the late group, detachment occurred in 12 of 18 ears (66.7%), which was statistically significant ( P < 0.01). The average period of applying devices was 4.7 ± 1.2 weeks in the early group and 8.5 ± 4.1 weeks in the late group, with a significantly longer treatment time in the late group ( P = 0.001). The early group had 87.1% good results versus 55.6% good results in the late group, with a statistically significant difference.

Conclusions: The correction period was shorter, detachment rate was lower, and treatment outcome was better in the early group. However, successful correction was also present in the late group, showing that the patients who have passed the optimum correction period should proceed after counseling.

Clinical question/level of evidence: Therapeutic, II.