Plastic and reconstructive surgery最新文献

Background: Shoulder function after spinal nerve grafting in pan-brachial plexus injuries (pan-BPI) is not well described. The authors evaluated shoulder abduction (ABD) and external rotation (ER) after spinal nerve grafting to the suprascapular nerve, axillary nerve, or posterior division of the upper trunk and determined patient characteristics, injury severity and characteristics, and nerve graft factors that influenced outcomes.

Methods: A total of 362 patients undergoing pan-BPI reconstruction and spinal nerve grafting for shoulder reanimation in a single institution between 2001 and 2018 were reviewed. Patient demographics, Injury Severity Score (ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into 3 groups based on recovery of shoulder function: no return, ABD only, and ABD and ER.

Results: A total of 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. Seventeen (41.5%) had no return of shoulder function, 14 (34.1%) had ABD alone, and 10 (24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger (18.6 ± 5.56 years), had lower body mass index (22.4 ± 4.0), and had a lower ISS (10.5 ± 6.24; P = 0.003). Multivariable analysis found that with increasing age (OR, 0.786; 95% CI, 0.576, 0.941) and ISS (OR, 0.820; 95% CI, 0.606, 0.979), odds for return of ABD and ER decreased significantly.

Conclusions: In pan-BPI, 24.4% of patients demonstrated return of both ABD and ER after spinal nerve grafting to suprascapular nerve and either axillary nerve or posterior division of the upper trunk. Age, body mass index, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, body mass index, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation.

Clinical question/level of evidence: Risk, III.

Background: The difficulty in obtaining long-term data with the use of breast implants is well known. The majority of available data are from multicenter studies with different surgical techniques, and different implants.

Methods: The authors provide retrospective 10-year study data (2001 to 2011) with Mentor Contour Profile Gel implants after a mean of 13 years of follow-up, in the first single-center study of such size and length. This study included 835 patients with 1674 Mentor implants across 6 surgery types, all of them performed with a consistent surgical technique developed by the senior author (J.L.M.Y.). Long-term complication rates were analyzed. For the safety analysis, Kaplan-Meier risk rates were calculated.

Results: A total of 85% of the patients had long-term follow-up data (at least 7 years). The overall complication rate was 13.2%. The reoperation rate was 12.3%, being just 6.2% caused by complications. The 21-year Kaplan Meier cumulative incidence rate was 1.7% for capsular contracture and 5.1% for implant rupture. The periareolar approach and having a previous capsular contracture were found to be risk factors to develop a new capsular contracture. Low-height, high-projected implants had a significant higher risk of implant rotation. No breast implant-associated anaplastic large cell lymphoma or breast implant illness cases were found; 89.2% of the patients reported being satisfied or very satisfied with the surgery and the implant.

Conclusion: With a consistent surgical technique, these 21-year follow-up data of the Mentor Contour Profile Gel implants reaffirm the very strong safety profile of these implants, and continued patient satisfaction with them.

Clinical question/level of evidence: Therapeutic, IV.

Background: Attempts to restore independent hand function in total brachial plexus injuries (TBPIs) have often failed due to inconsistent results of finger extension reconstruction. An innovative technique is described to achieve this effect by direct neurorrhaphy of residual (ruptured) roots with the middle trunk.

Methods: Direct coaptation of the ruptured roots to the middle trunk and, simultaneously, transferring the anterior division of the middle trunk to the posterior division of the lower trunk was performed in 64 patients with TBPI. The return of extension of the elbow, wrist, and fingers was monitored.

Results: Excellent and good muscle strength of finger extension were noted in 45.3% of cases. The patients were divided into group A (>32 years) and group B (≤32 years) according to receiver operating characteristic curve analysis. The difference of excellent and good rates of finger and wrist extension muscle strengths between the 2 groups was statistically significant (χ 2 = 4.635, P = 0.031; χ 2 = 6.615, P = 0.010).

Conclusions: Direct neurorrhaphy of ruptured nerve root stumps with the middle trunk could achieve satisfactory results for finger extension in TBPI for patients ≤32 years old. Long nerve defects (4 to 6.5 cm) could be overcome by freeing the nerve and adducting the arm against the trunk.

Clinical question/level of evidence: Risk, III.

Background: Patients with Dupuytren disease (DD) are mostly surgically treated by percutaneous needle fasciotomy (PNF) or limited fasciectomy (LF), but data on time intervals to retreatment are lacking. The authors aimed to estimate the risk of retreatment within certain time periods after treatment with PNF and LF.

Methods: The authors used data of participants of a cohort study on the course of DD who were treated only with PNF or LF. The primary outcome measure was time to retreatment of DD. The authors included sex, age at first treatment, and having a first-degree relative with DD as confounders in our analysis. A bivariate gamma frailty model was applied to estimate the risk of retreatment within 1, 3, 5, 10, and 20 years after treatment with PNF and LF.

Results: The time to retreatment was significantly shorter after treatment with PNF than after LF (Wald test statistic, 7.56; P < 0.001). The estimated 10-year risk of retreatment for men who underwent their first treatment at a younger age and with a first-degree relative with DD was 97% after PNF and 32% after LF. The estimated 10-year risk for women who underwent their first treatment at an older age without a first-degree relative with DD was 20% after PNF and 6% after LF.

Conclusions: The results show that the patients treated with PNF have a higher risk of retreatment. The results of this study could contribute to individualized information on the treatment durability in the future, which would improve patient counseling about the expected retreatment needs.

Clinical question/level of evidence: Therapeutic, III.

Summary: Rhinoplasty remains one of the most technically demanding operations in plastic surgery, and it continues to be one of the top 5 aesthetic surgical procedures performed. The focus of this article is open rhinoplasty, the central focus of the practice of the senior author (R.J.R.) over the past 3 decades. The authors provide a step-by-step video guide to the typical sequence of the senior author's technique.

Learning objectives: After studying this article, the participant should be able to: 1. Accurately diagnose scaphoid fractures through examination and appropriate imaging selection. 2. Recognize those fractures that can be treated with nonoperative management. 3. Outline the different surgical approaches for scaphoid fractures. 4. Appreciate the surgical options for management of scaphoid nonunion.

Summary: This article includes the most up-to-date information on the diagnosis, work-up, and treatment of scaphoid fractures.

Background: The treatment of postparetic facial synkinesis is based on a combination of nonsurgical and surgical strategies. Improvements toward the restoration of a natural smile have been obtained with selective neurectomies and depressor anguli oris myectomy, but the lower lip frequently remains asymmetric and cranially displaced. The aim of this study was to evaluate the effect of the mentalis muscle on the position and symmetry of the lower lip in patients with synkinesis and to assess the added benefit of neurectomies of nerves innervating the mentalis muscle in improving the lower lip configuration and mandibular teeth show.

Methods: A retrospective cohort study of all patients with postparetic synkinesis was performed at the authors' institution. A nonmentalis neurectomy group including 12 patients treated with selective neurectomies without targeting the branches to mentalis muscle was compared with a mentalis neurectomy group including 16 patients who underwent additional specific mentalis branches neurectomies. All patients underwent depressor anguli oris myectomy. Analyses of standardized images were performed with ImageJ software.

Results: Postoperative comparisons between the 2 groups showed superior and significant improvements in the mentalis neurectomy group across all measures, including lower and upper border deviation ( P = 0.035 and P = 0.004, respectively), inclination of the lower lip ( P = 0.019), and lower quadrant dental show ( P = 0.004).

Conclusion: The addition of targeted selective neurectomies to the branches innervating the mentalis muscle significantly improved dental show and caudal position and symmetry of the lower lip during open-mouth smile.

Clinical question/level of evidence: Therapeutic, III.

Background: Favorable behavioral interactions are critical for academic and interpersonal success. An association between metopic synostosis and behavioral impairments has not been fully elucidated. Behavioral dysfunction in school-age children with surgically corrected metopic synostosis was evaluated using targeted testing to detect the most common behavioral abnormalities in this population.

Methods: Parents of children 6 to 18 years of age with metopic synostosis completed the Conners Rating Scales, 3rd edition (Short Form) (Conners-3; attention-deficit/hyperactivity disorder), Social Responsiveness Scale, 2nd edition (SRS-2; autism spectrum disorder), Behavior Rating Inventory of Executive Function, 2nd edition (executive functioning), and Child's Behavioral Checklist (behavioral/emotional functioning). Children also completed neurocognitive testing. Multivariable regression was used to determine predictors of clinically significant behavioral impairments.

Results: Sixty children were enrolled. Average age at surgery was 9.2 ± 7.9 months, with an average age at assessment of 10.3 ± 3.5 years. Nearly half of patients demonstrated symptoms associated with attention-deficit/hyperactivity disorder, demonstrated by reaching or exceeding borderline clinical levels for inattention and hyperactivity subscales of the Conners-3. Greater age at surgery was associated with worse executive function, measured by reaching or exceeding clinically significant levels of the executive function subscale of the Conners-3 ( P = 0.04) and subscales of the Behavior Rating Inventory of Executive Function, 2nd edition (Behavioral Regulator Index [ P = 0.05], Cognitive Regulatory Index [ P = 0.03], and Global Executive Composite [ P = 0.04]).

Conclusions: Nearly half of patients with surgically corrected metopic synostosis reached borderline clinical scores for inattention and hyperactivity. Older age at surgery was associated with worse executive function. Prompt surgical correction of metopic synostosis may portend improved long-term emotional and behavioral function.

Clinical question/level of evidence: Therapeutic, III.

Background: Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution studies, and small sample sizes. Our study is the largest and first multicenter study to determine the predictors of postoperative diplopia following OBF repair.

Methods: The authors conducted a retrospective review of patients who underwent OBF repair at 2 centers from 2015 to 2019. The authors' primary outcome was the incidence or persistence of postoperative diplopia at least 2 weeks after OBF repair. Descriptive statistics were calculated. Multivariable logistic regression was performed to determine significant predictors of postoperative diplopia.

Results: Of 254 patients, the median age was 36.1 years (interquartile range, 27.8 to 50.7 years), and the median follow-up was 79.5 days (interquartile range, 40.3 to 157.3 days). The most common postoperative ocular symptom was diplopia (51 of 254 [20.1%]). Patients who had preoperative limited ocular motility or enophthalmos had greater odds of developing postoperative diplopia, compared with patients who did not have these preoperative symptoms (adjusted ORs, 2.33 [95% CI, 1.03 to 5.24] and 2.35 [95% CI, 1.06 to 5.24], respectively). Patients who had combined orbital floor and medial wall and moderate OBF (>2-cm 2 defect or >3-mm displacement) on preoperative computed tomographic scan had greater odds (adjusted ORs, 2.16 [95% CI, 1.04 to 4.46] and 3.77 [95% CI, 1.44 to 9.83], respectively) of developing postoperative diplopia, compared with patients without these preoperative computed tomographic findings.

Conclusion: During primary assessment of the patient with OBF, preoperative ocular signs and symptoms, fracture severity, and location of OBF are key predictors of postoperative diplopia.

Clinical question/level of evidence: Risk, III.