Plastic and reconstructive surgery最新文献

Summary: Patients with large amounts of neck skin redundancy who do not desire or are not candidates for traditional face and neck lifts can be managed with direct neck lifts. There are many surgical techniques to address central neck laxity. In this article, the authors present their surgical technique to address central neck laxity. The authors' clear video format showcases the 7 steps of their neck-lift Z-plasty.

Background: Traumatic hand injuries often present with high acuity, but little is known about the influence of geospatial and socioeconomic factors on the timely delivery of care.

Methods: This cross-sectional study used the Michigan Trauma Quality Improvement Program database, a statewide registry with 35 level I or II trauma centers. Adult patients sustained hand trauma requiring urgent operative treatment between 2016 and 2021. Zip codes of injury location were linked with the corresponding percentage score on the Area Deprivation Index (ADI), a comprehensive measure of neighborhood disadvantage. Multiple regression analyses were used to determine associations of patient, injury, and geospatial characteristics with the odds of sustaining acute hand trauma and time to operative treatment.

Results: Among 1826 patients, the odds of sustaining acute hand trauma based on the ADI followed a bimodal distribution. Female sex, smoking, obesity, work-related injury, and residence in a minor city were associated with increased odds, whereas younger age, comorbidities, and rural residence were associated with decreased odds. For 388 patients who underwent surgery within 48 hours, time to treatment was significantly increased in the highest ADI quintile, for patients who underwent fracture fixation, and for those with severe global injury severity. Multisystem injuries, moderate global injury severity, and direct admission to an orthopedic service were associated with shorter times to treatment.

Conclusions: Patients in areas with greater neighborhood disadvantage may experience delayed operative care after acute hand trauma. This study highlights the importance of considering underserved populations and geospatial factors when determining the allocation of hand surgery resources.

Clinical question/level of evidence: Risk, III.

Background: The success of upper blepharoplasty depends on both surgeon experience and skill and on patient factors. Therefore, the authors aimed to identify patient-specific characteristics that may contribute to poor prognoses by analyzing data derived from patients with various deformities after undergoing upper blepharoplasty.

Methods: This study included 202 patients who underwent revision surgery for upper blepharoplasty. The authors explored relationships between types of deformities before revisions and relevant patient factors before initial surgery using statistical analyses.

Results: Age older than 30 years, thick upper lid skin, medial epicanthus, and other patient factors were significantly associated with the deformities. Asymmetric crease, crease disappearance, shallow crease, and low crease were the most prevalent deformities. For these 4 most prevalent deformities, the concordance indices and 95% confidence intervals (95% CI) of the risk prediction models were 0.654 (95% CI, 0.575 to 0.734), 0.724 (95% CI, 0.637 to 0.810), 0.783 (95% CI, 0.702 to 0.863), and 0.750 (95% CI, 0.655 to 0.844), respectively.

Conclusions: Among the 4 most prevalent prognostic deformities, significant patient factors included medial epicanthus, thick upper eyelid skin, weak levator palpebrae superioris, age older than 30 years, and a short gap between eyes and brows. The authors also attempted to clarify the clinical importance of these patient factors. The authors' findings provide a guide and reference for future investigations into upper blepharoplasty.

Clinical question/level of evidence: Risk, III.

Summary: This article introduces a novel technique for refining the middle third of the nose in preservation rhinoplasty, adhering to the principles established by Teoman Dogan. The technique, applicable through both open and closed approaches, maintains the integrity of the nasal dorsum. The J-suture technique is particularly significant for addressing the widening of the middle third of the nose, a common issue in preservation rhinoplasty. This technique uses an absorbable percutaneous suture, allowing for the approximation of the upper lateral cartilages and thus thinning of the middle third of the nose. The authors discuss the technical aspects and advantages of the J-suture, emphasizing its simplicity, predictability, reproducibility, and ease of execution. The technique, requiring minimal training, can be adopted by any surgeon practicing preservation rhinoplasty. The J-suture represents a significant advancement in preservation rhinoplasty, providing a practical solution for enhancing nasal aesthetics, minimizing surgical trauma, and promoting patient well-being.

Background: Reduction malarplasty is effective in correcting prominent zygomatic body and arch in Asian populations, but periorbital zygomatic bony protrusion may not be sufficiently improved. In this study, the authors present the extended reduction malarplasty procedures to correct it simultaneously and compare the outcome with that of conventional L-shaped osteotomy.

Methods: A retrospective review of consecutive patients who underwent reduction malarplasty between August of 2021 and September of 2023 at the authors' hospital was conducted. Computed tomographic images obtained before and after surgery were assessed to evaluate the facial skeletal changes, and to compare between the extended and conventional L-shaped malarplasty results.

Results: Twenty patients with extended reduction malarplasty and 23 patients with conventional reduction malarplasty were eligible for the study. Cephalometric analyses showed significant reduction in the zygomatic width in both groups, but the protrusion of the periorbital area was improved significantly more in the extended reduction malarplasty group. In terms of facial angulation, the extended reduction malarplasty also provided more horizontal convexity in the periorbital area, whereas the angular change in the caudal part of the zygoma was not significantly different.

Conclusions: The extended reduction malarplasty enabled reduction of the protrusion of the periorbital area and the prominent zygomatic body and arch, and provided more 3-dimensionality and horizontal convexity with the midface contour. It is a viable option for harmonizing the facial profile for Asian patients with flat and wide faces.

Clinical question/level of evidence: Therapeutic, III.

Background: Some articles suggest that wide-awake flexor tendon repair (FTR) may reduce rates of postoperative tendon gapping and rupture because of improved intraoperative testing of the repair. The current study is a nationwide cohort study comparing FTRs performed wide-awake and with traditional anesthesia.

Methods: Patients undergoing zone II FTR between 2010 and 2022 were identified in PearlDiver. Exclusion criteria were other tendon repairs, concomitant treatment for vascular injury, fracture, dislocation or amputation, inpatient or office surgery, age younger than 18 years, and less than 1 year of follow-up. Patients were stratified by anesthesia technique: traditional anesthesia (general anesthesia, monitored anesthesia care, regional blocks) or wide-awake anesthesia. Patients were matched based on age, sex, Elixhauser Comorbidity Index score, geographic region, insurance coverage, number of tendon repairs, and presence of concomitant nerve repair. Thirty-day wound complications, emergency department visits and readmissions, and 1-year reoperations were identified. Total reimbursement for surgery was determined.

Results: Each matched cohort included 2563 patients. Wide-awake patients had fewer 30-day emergency department visits (2.7% versus 4.8%). There were no differences in 30-day wound complications or readmissions. There was no difference in 1-year reoperations for rupture or stiffness. Multivariable linear regression identified wide-awake surgery to be significantly associated with lower total reimbursement.

Conclusion: Performing digital FTR using wide-awake techniques can reduce costs, but the hypothesis that wide-awake repairs may reduce rates of tendon rupture was not supported by the current study.

Clinical question/level of evidence: Therapeutic, III.

Background: Traumatic peripheral nerve injuries can result in significant functional impairments and long-term sequelae. This study evaluated the long-term outcomes of a chitosan tube implant to protect epineural coaptation after peripheral nerve injuries using 2 different tube versions (different wall thicknesses and resorption characteristics), compared with a control group. The study focused on pain levels, sensory function, and overall functional outcomes.

Methods: Patients who received a tube implant around direct coaptation sites of digital nerves were randomized and compared with control patients with no additional tube protection. Pain levels, sensory function, grip force, and functional scores were assessed at time points ranging from 3 months to 5 years postoperatively. Tube biodegradation was measured using high-resolution magnetic resonance neurography and categorized.

Results: Patients with the first tube version had higher pain levels compared with the control group after 5 years, and reported more symptoms of numbness and hypersensitivity. Patients with the second version exhibited higher pain levels at 3 months that did not persist at 6 months, but they showed compromised sensory function, with higher 2-point discrimination values compared with the first and control groups. No differences were found in grip force or functional scores between the groups. Magnetic resonance imaging displayed remnants of implants even at long-term follow-up.

Conclusions: The findings suggest potential limitations attributable to increased pain and impaired sensory function associated with tube implantation in the long term. In the short term, however, the material seemed to have a protective effect (as published previously). The resorption process was not complete at the end of the 5-year observation period. This might explain the prolonged scarring and inferior long-term results. Future research should focus on improving tube materials and design to minimize adverse effects and enhance functional outcomes.

Background: Enophthalmos is a surgical indication for orbital fracture repair. However, guidelines to predict enophthalmos in orbital fractures are ambiguous. The authors systematically reviewed the existing literature on using computed tomographic findings to establish objective metrics to predict enophthalmos in asymptomatic patients during initial trauma work-up.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. PubMed and Embase were used to identify studies of interest. The Quality in Prognosis Studies tool was used for risk of bias assessment. Random-effects model meta-analyses of orbital volume change and fracture area values were completed. Regression analyses were performed to determine thresholds that predicted 2 mm of enophthalmos.

Results: Of the initial 2236 abstracts, 36 met inclusion criteria. Thirty retrospective studies evaluated a total of 2851 patients, and 6 prospective studies evaluated 211 patients. All 36 studies had predominantly low risk of bias. Predictors of enophthalmos assessed were orbital volume change (21 articles), fracture surface area (13 articles), inferior rectus muscle displacements (7 articles), and fracture location (4 articles). Studies reporting on orbital volume change offered values ranging from 0.69 to 4.26 cm 3 . Fracture area predictor values ranged from 1.50 to 3.38 cm 2 . Meta-analyses confirmed the validity of both predictors. Pooled regression analyses demonstrated that 3.33 cm 3 of orbital volume increase or fracture area of 3.12 cm 2 were predictors of 2 mm of enophthalmos.

Conclusions: Both orbital volume change and fracture area measured on computed tomographic scan are good predictors of late posttraumatic enophthalmos. Pooled data indicate that 3.12 cm 2 of fracture area or 3.33 cm 3 of orbital volume increase is predictive of enophthalmos.

Background: Traditional rhinoplasty tip grafts often lead to visibility issues, prompting patients to seek revision surgery. The mastoid fascia tissue graft (MFTG) provides a natural-appearing alternative with an acceptable risk of complication. The MFTG remains less visible through the skin and helps camouflage and conceal tip irregularities. This study of 193 patients examines the MFTG's effectiveness in nasal tip refinement, evaluating revision and infection rates.

Methods: A retrospective analysis of MFTG use for nasal tip appearance during open rhinoplasty in the senior author's (R.G.R.) practice was conducted, covering the period from January of 2019 to June of 2022. Inclusion criteria encompassed open rhinoplasty cases using mastoid tissue for tip appearance with at least 12 months of follow-up. Among 2003 cases, 193 met these criteria and were evaluated for subsequent revision and infection rates.

Results: The average patient age was 34.2 years (175 female patients and 18 male patients). Primary rhinoplasty was performed in 113 patients, with 80 receiving revision operations. The average follow-up was 14.8 months. Six patients (3.1%) overall needed extended antibiotics, including 1 primary rhinoplasty patient (0.9%) and 5 secondary rhinoplasty patients (6.3%). Overall, revision rhinoplasty was required in 6 patients (3.1%) (1 primary patient [0.9%] and 5 secondary rhinoplasty patients [6.3%]).

Conclusions: MFTG use for an aesthetically pleasing nasal tip appearance is a safe, convenient, and effective technique for camouflaging and concealing nasal tip contour irregularities in both primary and revision rhinoplasty. Use of the MTFG is associated with minimal morbidity.

Clinical question/level of evidence: Therapeutic, IV.