Plastic and reconstructive surgery最新文献

Background: Fresh autologous cranial bone graft has traditionally been regarded as the ideal cranioplasty material; however, long-term comparisons of outcomes with modern alloplastic materials are absent in the literature. The authors evaluated complications and failures among cranioplasties performed with fresh, heterotopic, cranial bone graft versus 3 common alloplastic materials.

Methods: Random-effects meta-analyses of logit-transformed proportions were performed on studies published between 1971 and 2021 to evaluate complications and failures of cranioplasties performed with fresh, autologous, heterotopic cranial bone; polyetheretherketone (PEEK); polymethylmethacrylate (PMMA); or titanium with a mean follow-up of 12 months or more. Generalized mixed model meta-regressions were performed to account for heterogeneity and to evaluate the contributions of moderators to outcomes variables.

Results: A total of 1490 patients (mean age, 33.9 ± 10.8 years) were included. Pooled, all-cause complications were 6.2% for fresh, heterotopic, autologous cranial bone (95% CI, 2.1% to 17.0%; I2 = 55.0; P = 0.02), 18.5% for PEEK (95% CI, 14.0% to 24.0%; I2 = 0.0%; P = 0.58), 26.1% for titanium (95% CI, 18.7% to 35.1%; I2 = 60.6%; P < 0.01), and 28.4% for PMMA (95% CI, 12.9% to 51.5%; I2 = 88.5%; P < 0.01). Pooled all-cause failures were 2.2% for fresh autologous cranial bone (95% CI, 0.4% to 10.6%; I2 = 0.0%; P = 0.45), 6.3% for PEEK (95% CI, 3.2% to 12.3%; I2 = 15.5%; P = 0.31), 11.4% for titanium (95% CI, 6.7% to 18.8%; I2 = 60.8%; P < 0.01), and 12.7% for PMMA (95% CI, 6.9% to 22.0%; I2 = 64.8%; P < 0.01). Meta-regression models indicated that each alloplastic subtype significantly and independently predicted higher complications, whereas titanium and PMMA were significant predictors for all-cause failures compared with autologous bone. All 3 subtypes were predictive of higher cranioplasty failures secondary to infection compared with autologous bone.

Conclusion: Cranioplasties performed with fresh, autologous, heterotopic cranial bone grafts resulted in lower complication and failure rates compared with alloplastic materials.

Background: In this study, the authors compared conventional and robot-assisted mastectomy and breast reconstruction. To the authors' knowledge, this study is the first to report the results of robot-assisted mastectomy and breast reconstruction and provide a comparison of patient-reported outcomes.

Method: This retrospective study included 473 breasts of 423 patients who underwent conventional mastectomy and breast reconstruction and 164 breasts of 153 patients who underwent robot-assisted mastectomy and breast reconstruction from July of 2019 to October of 2021. Demographic and oncologic data, reconstructive outcomes, and patient-reported outcomes (BREAST-Q) were evaluated. The results of implant-based and autologous breast reconstruction were evaluated separately.

Results: Skin necrosis requiring surgical débridement occurred significantly more frequently in the conventional group (8.0%) than in the robot-assisted group (2.0%) in implant-based reconstruction ( P = 0.035). At 6 to 12 months, patients who underwent robot-assisted breast reconstruction showed a higher Sexual Well-being score for implant-based reconstruction and a higher Physical Well-being score for autologous breast reconstruction than conventional breast reconstruction according to the BREAST-Q questionnaire.

Conclusions: Robot-assisted mastectomy and breast reconstruction was associated with less skin necrosis and better patient-reported outcomes (Sexual Well-being for implant-based reconstruction and Physical Well-being for autologous breast reconstruction) than the conventional option. Robotic surgery could be a good option for mastectomy and breast reconstruction.

Clinical question/level of evidence: Therapeutic, III.

Background: Early detection of rare genetic diseases, including velocardiofacial syndrome (VCFS), is essential for patient well-being. However, their rarity and limited clinical experience of physicians make diagnosis challenging. Deep learning algorithms have emerged as promising tools for efficient and accurate diagnosis. This study investigates the use of a deep learning algorithm to develop a face recognition model for diagnosing VCFS.

Methods: The study employed publicly available labeled face datasets to train the multitask cascaded convolutional neural networks (MTCNN) model. Subsequently, we examined the binary classification performance for diagnosing VCFS using the most efficient face recognition model. A total of 98 VCFS patients (920 facial photographs) and 91 non-VCFS controls (463 facial photographs) were randomly divided into training and test sets. Additionally, we analyzed whether the classification results matched the known facial phenotype of VCFS.

Results: The face recognition model demonstrated high accuracy, ranging from 94% to 99%, depending on the training dataset. The accuracy of the binary classification diagnostic model varied from 81% to 88% when evaluating with photographs taken at various angles, but reached 95% evaluating with frontal photographs only. Gradient-weighted class activation mapping heatmap revealed the high importance level of perinasal and periorbital areas, exhibiting consistency with the conventional facial phenotypes of VCFS.

Conclusion: This study shows the feasibility and effectiveness of MTCNN-based model for detecting VCFS solely from facial photographs. The high accuracy underscores the potential of deep learning in aiding early diagnosis of rare genetic diseases, facilitating timely interventions for patient care.

Summary: Corneal anesthesia, caused by lack of corneal innervation, is a rare but devastating condition that can lead to neurotrophic keratopathy, corneal ulceration, scarring, and blindness. Minimally invasive corneal neurotization enables transfer of regional donor sensory nerves to the cornea to provide sensation and ocular protection. The authors provide an update on technical advances and modifications that have refined the surgery over the past 10 years, as well as step-by-step intraoperative videos of corneal neurotization, noting its critical steps, pitfalls, and caveats. The videos illustrate the novel technique of using the greater auricular nerve with a sural nerve graft extension as the donor nerve for the procedure. The steps and considerations depicted will allow surgeons to carry out corneal neurotization efficiently, safely, and effectively.

Background: Facial nerve (FN) injury during a face lift is a relatively rare but potentially devastating complication. Despite extensive literature discussing FN anatomy and danger zones, few studies describe detailed management, FN exploration intraoperative findings, and outcome after post-face lift facial paralysis (PFFP). The authors reviewed a 20-year experience in managing iatrogenic PFFP.

Methods: Patients with PFFP were retrospectively identified between 2002 and 2022. Demographic data, operative details from the face lift procedure, facial function after face lift, medical and surgical management, intraoperative findings, and long-term outcomes were analyzed.

Results: A total of 25 patients who experienced PFFP were referred for evaluation over the past 20 years. Eight patients required FN exploration, 6 of whom underwent nerve repair; all recovered to some degree, with 50% achieving essentially normal facial function. Fourteen patients underwent nonsurgical management, including physical therapy, chemodenervation, and filler therapy. Of these nonsurgical patients who were not lost to follow-up, 50% achieved normal facial function and 42% achieved nearly normal facial function. The single patient who had no spontaneous improvement presented outside the reinnervation window and was not an operative candidate.

Conclusions: PFFP outcome depends on injury type and location, accurate assessment, and appropriate treatment; however, the overall prognosis is favorable. FN exploration is warranted when nerve transection is suspected. Observation is suitable for patients demonstrating early signs of recovery. Patients presenting beyond a reasonable reinnervation window will need other facial reanimation techniques. When FN exploration is required, outcomes may be superior in a facial nerve center setting. Adjunctive interventions for symmetry improvement while awaiting recovery are available.

Clinical question/level of evidence: Therapeutic, IV.

Background: Breast cancer patients face complex decisions about immediate breast reconstruction (BR) after mastectomy. The authors evaluated the efficacy of an online decision aid in improving the decision-making process, decision quality, and health outcomes in breast cancer patients considering immediate BR.

Methods: In a multicenter, randomized, controlled trial, patients were allocated to either the intervention group, receiving care as usual with access to an online decision aid, or the control group, receiving care as usual with an information leaflet. The primary outcome was decisional conflict. Secondary outcomes assessed the process of decision-making (eg, preparation for decision-making, satisfaction with information), decision quality (decision regret, knowledge), and health outcomes (eg, satisfaction with BR outcomes, body image). Patients completed questionnaires at time (T) 0 (baseline); T1 (1 week after consultation with a plastic surgeon); and T2 (3 months) and T3 (12 months) after surgery.

Results: The authors included 250 patients. Decisional conflict decreased over time in both groups, with no between-group differences. Intervention participants felt better prepared for decision-making than controls ( P = 0.002). At T2, 87% of intervention participants were very satisfied with the information about BR, compared with 73% of control participants ( P = 0.011). No significant between-group differences were observed in any other outcome.

Conclusions: The authors' online decision aid was as effective in reducing decisional conflict as an information leaflet about immediate BR after mastectomy. However, the decision aid substantially improved the decision-making process by better preparing breast cancer patients for decisions about immediate BR.

Clinical question/level of evidence: Therapeutic, II.

Summary: Nearly half of all patients undergoing plastic surgery are middle-aged cisgender women, all of whom will experience menopause. Plastic surgeons do not treat menopause directly, but it can be a concern-and even a motivating factor-for patients seeking plastic surgery. In addition, the changes associated with menopause underlie problems that many plastic surgeons seek to address, including with face lifts, breast surgery, and vaginal rejuvenation. Hormone replacement therapy has the potential to improve quality of life by treating bothersome symptoms and delaying the physical changes brought on by loss of estrogen. However, recent reports in the media highlight that women face significant barriers to accessing menopause care due to a lack of trained providers willing to manage hormone replacement therapy, as well as historical concerns regarding increased cancer risk, which recent evidence suggests were overestimated. Plastic surgeons may be the first, or only, providers with whom women discuss how their bodies change with age. As a result, plastic surgeons should consider menopause as an underlying risk factor or comorbidity for any woman presenting with aging-related complaints, and to ensure that these patients have access to appropriate menopause care in their communities. This is especially important for surgeons offering vaginal rejuvenation therapies, given that locally acting topical estrogen is a safe and highly effective treatment. The authors present guidance and recommendations for how plastic surgeons should take menopause into account when evaluating and advising patients. In addition, the authors present a treatment algorithm for safe prescribing of locally acting hormone replacement therapy for vaginal rejuvenation.