Plastic and reconstructive surgery最新文献

Summary: Facial buttresses are supportive bony structures of the facial skeleton that form a thick, strong, and protective framework for the face. Surgical fixation may be required to restore morphology and function when damage to these buttresses occurs. The authors sought to determine whether, similar to buttresses of the facial skeleton, buttresses of the internal orbit exist. They analyzed 10 human cadaver skulls imaged by microcomputed tomography. Image processing, and thickness and heat mapping, were performed using Avizo and ImageJ software. After identifying the orbital buttresses, the authors reviewed computed tomography scans of patients who had orbital fractures over a 3-year period to determine the frequency of fracture of the orbital buttresses. The authors identified 5 buttresses of the internal orbit: superomedial fronto-ethmoidal strut with the deep orbital buttress, inferomedial strut with the posterior ledge, inferior orbital fissure, sphenoid-frontal superolateral strut, and the sphenoid lip. The mean (SD) threshold orbital buttress thickness was 1.36 (0.25) mm. A total of 1186 orbits of 593 individuals were analyzed for orbital buttress involvement. Orbital buttresses were spared in 770 (65%) orbits. The inferomedial strut with the posterior ledge was the most commonly fractured buttress in 14.4% of orbits ( n = 171), followed by the sphenoid strut and lip (66 [5.6%]). To the authors' knowledge, this is the first description of the buttresses of the internal orbit. Orbital reconstruction for fracture repair or oncologic purposes requires the support of orbital buttresses. Understanding the anatomy of orbital buttresses is crucial for successful surgical planning, proper implant positioning, and restoration of function and appearance.

Summary: The noninferiority trial, a distinct category within randomized controlled trials, is garnering increased attention in medical research. Its unique and evolving role comes to the forefront in scenarios where new treatments, despite not surpassing the efficacy of an existing standard, bring additional benefits such as reduced side effects, enhanced compliance, or cost savings. As the field of surgery witnesses a growing number of published noninferiority trials, it becomes imperative for surgeons to grasp the intricacies of this trial type to accurately decipher and interpret their outcomes.

Background: Gracilis free muscle transfer (GFMT) remains the standard for smile restoration in patients with longstanding facial palsy. Resting oral commissure lateralization (ROCL) following GFMT is aesthetically unappealing and can cause functional problems including dysarthria and oral incompetence. The risk factors for ROCL following GFMT are poorly understood.

Methods: Of all patients who underwent GFMT for smile restoration from 2003 to 2021, patients with subsequent ROCL were identified from a facial nerve database using predetermined search criteria. Medical records were reviewed to identify potential risk factors for muscle foreshortening.

Results: Of 412 patients who underwent successful GFMT since 2003, 41 patients (10%) subsequently developed ROCL. ROCL rates varied significantly based on gracilis innervation source, with ipsilateral cranial nerve VII innervation and dual innervation (crossfacial nerve graft plus ipsilateral-to-masseter nerve) demonstrating the highest foreshortening rates (27.3% and 15.4%, respectively), compared with the lowest rates of foreshortening when the gracilis muscle was innervated by the crossfacial nerve graft alone (3.2%) ( P = 0.005). Patients with a history of irradiation to the surgical field were significantly more likely to develop ROCL (22%) compared with those without a history of irradiation (8.6%) ( P < 0.001). Furthermore, the rate of ROCL was significantly higher among patients who underwent concurrent stabilization of the nasolabial fold using a wide band of fascia lata (20.8%), compared with those who did not (6.6%) ( P < 0.001).

Conclusion: The authors report potential risk factors for ROCL following GFMT for smile restoration, including innervation source, radiation history, and concurrent fascia lata static suspension.

Clinical question/level of evidence: Therapeutic, III.

Background: This study aimed to validate the use of grayscale muscle ultrasound by measuring echo intensity to longitudinally evaluate functional muscle reinnervation in a rabbit peroneal nerve defect model.

Methods: Eighteen New Zealand white rabbits underwent a 30-mm peroneal nerve reconstruction with autografts or decellularized allografts. Ultrasound measurements of tibialis anterior muscles were performed before surgery and at 4, 8, 12, 16, 20, and 24 weeks postoperatively and included cross-sectional muscle area, mean gray value (MGV), and mean gray value normalized for area (MGVA). At 24 weeks, functional motor recovery was evaluated with isometric tetanic force (ITF) and compound muscle action potential (CMAP). MGVA data were compared with ITF and CMAP measurements by calculating the Spearman correlation coefficient.

Results: Muscle area (left/right [L/R] ratio) of autografts was superior to allografts at 4, 12, 16, 20, and 24 weeks ( P < 0.03 for all comparisons). MGVs of the operated side were significantly higher for autografts at 4, 8, and 12 weeks and at 12, 16, 20, and 24 weeks for allografts ( P < 0.01 for all comparisons), compared with their unoperated sides. Similar patterns were seen in both groups for MGVA (operated versus control side). MGVA (L/R) demonstrated a strong correlation with ITF (L/R) for autografts (ρ = -0.7) and allografts (ρ = -0.87), but inconsistent with CMAPs (L/R).

Conclusions: Quantitative muscle ultrasound demonstrated a reliable, noninvasive tool for evaluating motor recovery in a rabbit peroneal nerve reconstruction model. Clinical translation could provide valuable insights into muscle health and structural changes following nerve reconstruction.

Summary: Secondary breast reductions are increasingly being performed, but they are potentially associated with higher complication rates than primary mammaplasty. Necrosis of the nipple-areola complex (NAC) is a devastating complication that can occur after repeated NAC transposition, particularly when the initially used pedicle is unknown. Thus, the authors established a modification of the McKissock technique for secondary breast reductions including 3 pedicle components to ensure safe vascular supply of the NAC. The presented technique incorporates a superior and inferior dermoglandular pedicle, according to the McKissock technique, and an additional central pedicle. The technique was applied for secondary breast reduction in a series of 25 breasts (14 patients: 11 bilateral, 3 unilateral). Complication rates, preoperative and postoperative BREAST-Q scores, and aesthetic outcomes were evaluated. Mean resection weight was 299 g (range, 40 to 646 g), and the NAC was transposed by 4.2 cm on average (range, 1 to 10 cm). No case of NAC necrosis was observed, and comparison of preoperative and postoperative BREAST-Q values indicated substantial improvement in all domains. After surgery, 84.6% of patients reported excellent satisfaction with breast appearance. According to these results, the modified McKissock technique is safe for patients requiring secondary breast reduction, even if the primarily used pedicle is unknown. The established technique is associated with improved postoperative patient-reported outcomes and yields aesthetically favorable results.

Clinical question/level of evidence: Therapeutic, IV.

Background: Patients with cleft have functional and aesthetic impairment, and typically require several interventions as they grow. Long-term evaluation following a treatment protocol is essential, but such reports on patients with complete cleft lip and alveolus (CLA) are sparse in the literature.

Methods: A retrospective review was conducted of all patients with complete CLA born between January of 1995 and August of 2002 and treated at our center. Patients who received continuous multidisciplinary team care until 20 years of age were included, and patients with cleft palate and syndromic abnormalities were excluded. Facial bone growth was evaluated using cephalometric analysis.

Results: Eighty-seven and 11 patients with unilateral and bilateral CLA, respectively, were included. All patients underwent one-stage cheiloplasty with primary rhinoplasty. Revision lip/nose surgery was performed in 21.8% and 27.3% during growing age, and in 51.7% and 72.7% after skeletal maturity, respectively. Orthognathic surgery was performed in 20.7% and 27.3%, respectively. Compared with unilateral CLA patients, bilateral CLA patients had more operations (3.0 versus 3.7; P = 0.03) and a higher chance of undergoing alveolar bone grafting twice (1.1% versus 36.4%; P < 0.01). Patients with complete CLA had less hypoplastic maxilla, and underwent fewer operations than those with complete cleft lip and palate.

Conclusions: Complete CLA is a less severe form of cleft, but the patients still require multiple interventions. This review revealed certain suboptimal results, and modifications have been made in the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Background: The purpose of this study was to evaluate whether the sequence of osteotomies influences the accuracy of maxillary positioning in patients with cleft palate with or without cleft lip undergoing bimaxillary orthognathic surgery (OGS).

Methods: This was a prospective study of patients with Veau II through IV clefts who underwent bimaxillary OGS at a tertiary-care children's hospital over a 3-year period. The primary predictor variable was the sequence of osteotomies (maxilla first versus mandible first). The primary outcome of interest was the concordance between the planned and achieved maxillary position, as assessed using linear and angular measurements. Secondary study predictors were demographic and surgical variables. Differences between groups were compared using nonparametric independent samples tests for continuous measures (data reported as median and interquartile range) and chi-square tests for categorical measures. For all analyses, P ≤ 0.05 was considered significant.

Results: Participants who underwent maxilla-first ( n = 15) and mandible-first ( n = 16) operations were comparable with regard to age, sex, cleft type, skeletal classification, segmental maxillary osteotomy, and magnitude of maxillary movement ( P ≥ 0.09). The planned sagittal and vertical positions of the maxilla were similarly accurate between the 2 groups ( P ≥ 0.68). Angular accuracy was also comparable ( P ≥ 0.56) between the study groups.

Conclusion: In patients with cleft palate with or without cleft lip undergoing bimaxillary OGS, use of mandible-first sequencing, when compared with maxilla-first sequencing, does not affect the accuracy of maxillary positioning in the immediate postoperative period in well-selected patients.

Clinical question/level of evidence: Therapeutic, II.

Background: The authors report the techniques and results of contiguous dorsal cross-shaped advancement flaps for reconstruction of 3- or 4-finger syndactyly in a single-stage operation for congenital syndactyly.

Methods: Thirty-five patients with multiple-finger syndactyly who received webspace reconstruction using the contiguous dorsal cross-shaped advancement flaps in a single operation were retrospectively studied. The patients ranged in age from 5 to 96 months (average age, 29.6 months). The contiguous dorsal cross-shaped flaps were advanced to reconstruct both webspace and lateral walls of the bases of the conjoined fingers. Withey grading was used for postoperative evaluation of web creep. Scar hyperplasia was assessed using the Vancouver Scar Scale. A visual analog scale of 0 to 10 was applied to evaluate the subjective satisfaction of the parents.

Results: In all cases, the syndactyly was successfully released in a single operation. There were no perioperative complications in this group. During a 12- to 58-month follow-up period, all reconstructed webspaces exhibited satisfactory appearance, and there was no obvious web creep. The dorsal hand scars were acceptable. Revision surgery was not needed in any patient. The average web creep was 0.45, and the average Vancouver Scar Scale score was 1.6. The average visual analog scale score for appearance was 1.2, and that for function was 2.5.

Conclusions: Multiple syndactyly release in 1 stage is feasible and safe. The contiguous cross-shaped flaps can be used to reconstruct 2 or more webspaces simultaneously after releasing.

Clinical question/level of evidence: Therapeutic, IV.

Background: Frontoorbital advancement and remodeling (FOAR) is a common surgical approach used for craniosynostosis, conferring functional and aesthetic benefit. There are few reports examining predisposing factors for postoperative complications within the first year after surgery. This study aimed to establish complication rates and identify risk factors for inferior outcomes in a large population of patients undergoing FOAR.

Methods: All patients who underwent FOAR from 2013 through 2022 at the authors' institution were retrospectively studied. Perioperative and postoperative data were collected to yield outcomes analyses. Multivariable logistic regression with backward selection was performed to identify predictors of postoperative complications.

Results: A total of 267 patients underwent FOAR. The overall complication rate was 14.2%, most commonly delayed wound healing (7.4%), postoperative blood transfusion (5.8%), and infection requiring readmission (1.9%). Tense closure independently predicted delayed wound healing ( P < 0.001) and infection requiring readmission ( P = 0.03). Syndromic patients were more likely than nonsyndromic patients to have undergone previous craniofacial surgery (45.3% versus 23.8%; P = 0.003). Syndromic status and previous craniofacial surgery were associated with increased risk of developing infection requiring readmission ( P = 0.012 and P = 0.004, respectively). A greater proportion of malnourished patients experienced postoperative complications compared with patients without malnourishment (24.4% versus 12.1%; P = 0.031), although there were no significant differences in individual postoperative outcomes.

Conclusions: Identified risk factors for complications included syndromic status, tense closure, and previous craniofacial surgery. Most complications were managed nonoperatively. These factors may be considered in preoperative planning and when counseling families.

Clinical question/level of evidence: Risk, III.