Plastic and reconstructive surgery最新文献

Introduction: Autologous breast reconstruction (ABR) following postmastectomy radiotherapy (PMRT) is often delayed several months due to adverse effects of radiation on outcomes. The optimal time between PMRT and ABR remains uncertain. We sought to analyze how the timing of ABR following PMRT affects postoperative outcomes.

Methods: A retrospective analysis was performed on adult female patients who underwent ABR. Cases were analyzed on a per-flap basis and were stratified into PMRT and non-PMRT groups. The PMRT group was further stratified into cohorts based on the time from completion of PMRT to ABR defined as: 0-3 months, 3-6 months, 6-12 months, and 12+ months. Primary outcomes included flap failure or necrosis and immediate reoperation. All other complications were secondary outcomes. Group differences were assessed using Chi-squared, Fischer's exact, Kruskal-Wallis and Wilcoxon rank sum tests. A logistic mixed-effects model was conducted to identify variables associated with postoperative complications.

Results: 514 flaps among 339 patients were included. 37.2% of the flaps were performed following PMRT: 5 within 0-3 months, 72 within 3-6 months, 71 within 6-12 months, and 43 within 12+ months. There were no statistically significant differences in reoperations, flap thrombosis, flap failure, infection, wound dehiscence, or operative time when comparing cases with or without PMRT and no statistically significant differences when comparing cases at the various time intervals.

Conclusion: No statistically significant differences in postoperative complications were observed across PMRT timing intervals. These findings do not support a strong association between the interval from radiotherapy to ABR and complication rates.

Clinical question/level of evidence: Therapeutic, IV.

Background: Developmental and behavioral issues are frequently reported in patients with metopic synostosis. The effect of pre-operative severity and surgical timing on these outcomes remains debated and inconclusive. This study aims to describe neurocognitive profiles in patients with metopic synostosis and evaluate associations with pre-operative severity and surgical timing.

Methods: A retrospective study was conducted on patients with non-syndromic metopic synostosis who underwent fronto-orbital advancement (FOA) at Sophia Children's Hospital. Patients were born between 2006-2018 and had a minimum 6-year follow-up. Data from psychological/psychiatric diagnostic assessments were collected, including WPPSI and WISC. Pre-operative severity was determined using CranioRate.

Results: A total of 228 patients with non-syndromic metopic synostosis who underwent FOA (median age 10 months, IQR 8-12) were included. Among these, 48.2% had reported parental concerns regarding their child's developmental and behavioral functioning. In total, 99 patients underwent psychological/psychiatric assessment, of which 73 patients underwent assessment at our center at the mean age of 7.8 years. Among referred patients, full scale IQ (FSIQ) (mean 95.5, p 0.012) and processing speed index (mean 94.3, p 0.002) were significantly lower compared to normative means. No significant association was found between FSIQ and pre-operative severity or surgical timing. Among all patients who underwent assessment, 43 were diagnosed with attention deficit/hyperactivity disorder and 13 were diagnosed with autism spectrum disorder, representing 18.9% and 5.7% of the total cohort respectively.

Conclusion: In this single-center cohort, cognitive and behavioral outcomes in children with metopic synostosis are not associated with pre-operative severity or surgical timing. However, parental concerns are common, and the increased prevalence of behavioral problems in this population highlights the importance of long-term neurodevelopmental monitoring.

Background: For women in the United States desiring implant-based breast reconstruction, the maximum volume of commercially available silicone breast implants has, to date, been 800cc. We evaluated the safety of MENTOR® larger-size MemoryGel® Ultra-High Profile breast implants (≥930cc) in women undergoing postmastectomy breast reconstruction.

Methods: This 10-year, multicenter, open-label, prospective, investigational study assessed the safety and effectiveness of larger-volume implants in women undergoing postmastectomy 2-stage primary or revision reconstruction. Three-year Kaplan-Meier curves and multivariable Cox regression analyzed the association between patient and treatment characteristics and surgical outcomes. Breast-Q was used to assess effectiveness at 3 years.

Results: Four hundred women were enrolled (225 primary, 175 revision reconstruction). Mean body mass index (BMI) was 35.8 kg/m2; 81% had a BMI ≥30 kg/m2. At 3 years, the cumulative incidence of postoperative complications (excluding rupture) was 63.0% (95% confidence interval [CI], 58.1-67.9). The reoperation rate was 24.5% (95% CI, 20.4-29.1), and the explantation rate was 15.8% (95% CI, 23.5-19.9). Independent predictors of complications included radiation and a history of smoking. There were no significant associations between postoperative complications and implant volume ≥1135cc or <1135cc. Breast-Q scores at Year 3 showed significant improvements from baseline in satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being (all P<0.0001). The mean score for satisfaction with outcome was 79.9.

Conclusions: These 3-year results demonstrate that larger-volume silicone breast implants represent a safe and effective option for patients with larger breasts who are requesting postmastectomy implant-based reconstruction.ClinicalTrials.gov Identifier: NCT02724371.

Background: The posterior radial collateral artery perforator free flap (PRCA flap) is a modification of the lateral arm flap that provides pliable tissue, color match, and primary donor-site closure. However, evidence on pedicle length remains limited, particularly in Asian populations. This study evaluated pedicle length stability and its correlation with body size.

Methods: A retrospective review was performed of 100 consecutive PRCA flap reconstructions for head and neck defects at Taipei Medical University Hospital between 2016 and 2024. Demographics, defect sites, flap dimensions, pedicle length, perforator location, recipient vessels, ischemia time, and donor-site closure were analyzed. True pedicle length was defined as the vascular segment from the selected perforator to the proximal transection point, excluding segments with only soft tissue. Correlations with height, arm length, and BMI were tested using regression.

Results: The mean age was 55.5 years (range, 27-84), and 85% were male. Malignancies accounted for 80% of defects, most commonly buccal mucosa (40%) and tongue (36%). The mean skin paddle measured 7.4 × 4.3 cm, and mean pedicle length was 9.7 ± 1.4 cm (range, 6-14 cm). The distal perforator was 4.7 ± 1.5 cm proximal to the lateral epicondyle. Pedicle length showed no correlation with height (R² = 0.022), arm length (R² = 0.004), or BMI (R² = 0.013). All donor sites were closed primarily.

Conclusions: The PRCA flap provides a reliable pedicle length independent of patient height and habitus, supporting its role as a safe, versatile option for small- to medium-sized head and neck reconstructions, particularly in Asian populations.

Introduction: The depressor-labii-inferioris (DLI), depressor-anguli-oris (DAO), mentalis, and platysma muscles control lower lip position-essential for smiling and oral function-and are at risk during facial reconstructive and aesthetic procedures. Prior anatomical studies, lacking functional analysis, suggested the marginal mandibular nerve (MMn) significantly contributes to mid-lower lip depression through DLI innervation. This study systematically assessed the functional anatomy and innervation of these muscles and evaluated whether MMn injury worsens lower lip position.

Methods: A retrospective cohort study of prospectively collected data included adult synkinesis patients undergoing selective neurectomies and myectomies with unilateral facial nerve mapping. Intraoperatively, facial nerve branches were stimulated and categorized by muscle activation patterns. Additional sub-analysis evaluated lower lip position changes using pre- and postoperative photographs in patients who underwent MMn neurectomy without platysma myectomy.

Results: Of 82 patients, 45 met inclusion (mean age: 51.5; 87% female). An average of 11.3 nerve branches were mapped per patient: zygomatic (2.80), buccal (4.36), MMn (1.16), and cervical (3.02). DAO and mentalis demonstrated mixed innervation patterns. DLI and platysma were predominantly cervical; 95.5% of DLI branches were cervical with 68.8% being pure DLI branches. In the sub-analysis (n=24), MMn neurectomy did not worsen lower lip position.

Conclusions: The DAO, mentalis, and platysma muscles are poly-innervated by buccal, MM, and cervical branches, while the DLI is mostly mono-innervated by cervical branches. Isolated MMn injury rarely worsens lower lip position, while injury to cervical branches to the DLI causes abnormal lower lip elevation and can be avoided by more caudal platysma myotomy.

Purpose: Massive weight loss after bariatric surgery is often associated with alterations in breast morphology, including ptosis, excess skin, poor tissue elasticity, and altered nipple position, which frequently motivate requests for breast surgery. However, data on implant-based augmentation after massive weight loss are sparse and often limited to small series. This study aimed to compare surgical techniques and implant selection in post-bariatric patients versus non-bariatric women undergoing primary augmentation.

Methods: We conducted a national, population-based case-control study within the Breast Reconstruction After Bariatric Surgery protocol (NCT07059104). Patients occurring in both the Scandinavian Obesity Surgery Registry and the Swedish Breast Implant Registry were identified. A non-bariatric control group having breast augmentation was created.

Results: A total of 817 post-bariatric patients (1634 breasts) and 3512 controls (7023 breasts) were analysed. Surgery occurred a median of 3.4 years after bariatric surgery. Post-bariatric patients reported greater dissatisfaction with breast volume. They more often received larger implants, round shapes, and micro- or macro-textured or polyurethane surfaces. Dual-plane or submuscular placement was predominant in both groups, whereas subfascial and subglandular placements were less common in post-bariatric patients. Augmentation mastopexy was more frequent, while the use of mesh/ADM and lipofilling remained rare. Postoperative antibiotics were prescribed more often to post-bariatric patients.

Conclusion: Breast augmentation after massive weight loss differs from standard practice, with larger and more textured implants and a higher frequency of mastopexies, highlighting surgical adaptation to complex anatomy.

Background: Discrepancies between assigned and actual operative durations may distort time-based valuation of surgical procedures. This study evaluated the impact of operative time source on wRVU per minute and reimbursement per minute across commonly reimbursed reconstructive plastic surgery operations.

Methods: Using 2023 National Surgical Quality Improvement Program (NSQIP) data, we compared actual operative times for 11 commonly reimbursed plastic surgery procedures to CMS-assigned times from the Physician Fee Schedule. Each CPT (15830, 19316, 19318, 19325, 19340, 19342, 19357, 19364, 19370, 19371, 19380) was linked to its CMS-assigned wRVU. wRVU per minute and reimbursement per minute were calculated using both NSQIP-observed and CMS-assigned operative times. Statistical analyses included Wilcoxon signed-rank tests, Kruskal-Wallis tests, Spearman correlations, and multivariable linear regression.

Results: Among 6,537 single-CPT cases, CMS underestimated operative time in 5 of 11 procedures. The largest discrepancies were observed in immediate implant insertion (+93.5 min), free flap breast reconstruction (+60.5 min), and breast augmentation (+18.5 min), resulting in reduced wRVU/min and $/min. Time discrepancy correlated strongly with reduced wRVU/min (ρ=-0.84). NSQIP-modeled reimbursement showed 2,637 single-CPT cases (40.3%) as underpaid, totaling $751,149.18. Among 15,570 multi-CPT cases, 5,099 (32.7%) were under-reimbursed, with a cumulative modeled underpayment of $2,002,956.29.

Conclusions: CMS operative times frequently underestimated the duration of plastic surgery procedures. Time discrepancies were associated with substantial reductions in wRVU/min and $/min, particularly for complex or implant-based operations. These findings suggest that current CMS time assignments do not adequately capture operative complexity and may contribute to systematic underpayment in reconstructive surgery.

We describe a novel technique for a single stage nailbed preserving debulking procedure for macrodactyly used in our unit. This simple technique preserves the perfusion and venous drainage of the nailbed complex by a subperiosteal dissection and the use of a dermal bridge by de-epithelialisation of the proximal area and subsequently folding the nailbed flap back onto itself in a pleated fashion. Four toes in three patients were treated with this technique and all achieved a shorter and less bulky appearance with nail preservation at a 2 year follow up. We believe that the single stage pleated nailbed flap is a simple and robust method of nail complex preservation in cases of macrodactyly debulking, which gives good cosmetic results and high patient satisfaction.

Introduction: Ventral hernia repair in oncologic patients is challenging due to poor tissue quality, immunosuppression, malnutrition, and prior operations. Limited data exists comparing the outcomes of biosynthetic (Poly-4-hydroxybutyrate) and synthetic mesh in this population. This study aims to assess the outcomes in patients who undergo hernia repair using one of two mesh types.

Methods: Patients undergoing ventral hernia repair by the Plastic and Reconstructive Surgery service and general surgery after oncologic resection from 2010 to 2023 were included, with patient records reviewed and cases identified in a prospectively maintained database by the Plastic and Reconstructive Service. Repairs were done in a retrorectus, underlay, or onlay fashion with either biosynthetic or synthetic mesh. Primary endpoints included complication rates (hematoma, infection/cellulitis, wound dehiscence, abscess, seroma) and hernia recurrence.

Results: 207 patients underwent repair (102 biosynthetic, 105 synthetic) and were included. Baseline demographics were similar between groups. No significant difference was observed in complication rates (biosynthetic: 24%, synthetic: 18%; p=0.3). Hernia recurrence was noted in 8.8% of biosynthetic and 6.7% of synthetic mesh cases (p>0.6). Subgroup analysis of wound classes II-IV showed consistent results. Up to two years postoperatively, synthetic mesh did not significantly reduce hernia recurrence risk compared to biosynthetic mesh (Subdistribution Hazard Ratio (sHR): 0.66; 95% CI, 0.27-1.59; p=0.4). Bilateral external abdominal oblique release (sHR: 0.31; 95% CI, 0.11-0.87, p=0.026) and retromuscular mesh placement (sHR: 0.08; 95% CI, 0.02, 0.35, p<0.001) exhibited a protective role.

Conclusion: Biosynthetic mesh can be considered a reasonable alternative to synthetic mesh in this high-risk population.