Plastic and reconstructive surgery最新文献

Background: Tip refinement procedures are still controversial in secondary unilateral cleft rhinoplasty. The aim of this study was to assess whether the septal extension graft improved nasal and tip deformity and achieved a normal profile with clinical and three-dimensional morphometric analyses.

Methods: A consecutive series of 194 skeletally mature patients with unilateral cleft were included and analyzed. All had undergone secondary open rhinoplasty, performed by a single surgeon, with the use of the septal extension graft between 2013 and 2021. Clinical data were collected, and three-dimensional morphometric measurements were performed. An age-, sex-, and ethnicity-matched normal group was included for comparisons.

Results: The authors' standard procedures included open approach combining reverse-U incision, septal extension graft, dorsal augmentation, lip revision, and vermilion augmentation. The postoperative outcome showed significantly increased numerical values (nasal bridge length, nasal height, nasal tip projection, nasal dorsum angle, columellar angle, columellar-lobule angle, nostril height ratio, nasal surface area, nasal volume) and decreased numerical values (alar width, tip/middle deviation, nasal tip angle, labial-columellar angle) compared with the preoperative morphology. The postoperative measurement showed significantly higher numerical values (nasal protrusion, tip/middle deviation, nasal dorsum angle) and lower numerical values (columellar-lobule angle, nostril height ratio, alar width ratio) compared with the control group.

Conclusions: This study revealed that the authors' secondary cleft rhinoplasty significantly improved the underprojected, up-rotated, deviated, and poorly defined tip and short nasal bridge deformities. The technique could result in the nose of the patients with cleft lip nasal deformity being closer to that of the normative profile.

Clinical question/level of evidence: Therapeutic, IV.

Background: In patients with craniosynostosis, the authors evaluated the diagnostic accuracy of fundoscopy and optical coherence tomography (OCT) to detect intracranial hypertension (ICH), the time course of retinal thickness after treatment of ICH, and the relationship between high hyperopia (HH) and fundoscopy/OCT scan findings.

Methods: Patients with syndromic, multisuture, unicoronal, unilambdoid, or sagittal synostosis visiting the authors' national center were included in this longitudinal cohort study and formed a consecutive series. Retinal layers on OCT, OCT fundus images, and fundoscopy results were evaluated. ICH was scored according to presence of abnormal intracranial pressures, hydrocephalus, progressive cerebellar tonsillar herniation or fingerprinting, and growth arrest. Diagnostic accuracy of OCT, fundoscopy, and fundus image; the time course of retinal thickness after ICH; and interference of HH were analyzed using linear mixed models.

Results: A total of 577 OCT scans in 307 patients were included. ICH was found in 7.2%. Combining total retinal thickness (TRT), OCT fundus imaging and fundoscopy resulted in a sensitivity of 76% and 81% specificity to detect signs of ICH. TRT was increased in patients who had had signs of ICH versus patients who had never had signs of ICH (β +44.9 µm in patients who had had ICH [95% CI, 9.0 to 80.8]; P = 0.01). TRT decreased to normal in the years after surgery (β -3.6 µm/yr [95% CI, -7.2 to -0.05]; P = 0.047). There were greater odds of having increased TRT in patients with HH (OR, 2.9 [95% CI, 1.1 to 7.6]; P = 0.03).

Conclusions: The correlation among TRT, OCT fundus image, fundoscopy, and particularly the combination of these measures with intracranial pressure surrogate markers is fair. Increased TRT in the presence of a clinical suspicion of ICH warrants further screening.

Clinical question/level of evidence: Diagnostic, III.

Background: The CLEFT-Q is a validated instrument designed to elicit patient-reported outcomes among people affected by cleft lip and/or palate. However, it has not been reported how use of CLEFT-Q data alters routine cleft care. This study analyzed the impact of CLEFT-Q data integration on patient care and clinical decision-making.

Methods: Patients were sequentially, prospectively evaluated during scheduled cleft team visits. The CLEFT-Q was completed before the clinic encounter, but results were initially masked from the surgeon and family. In the encounter, a study observer characterized patients' verbalized attitudes across 7 specific domains of appearance and function, and the provisional assessment and plan was noted. CLEFT-Q data were then introduced into the clinical encounter and discussed. Discordance between patients' initially verbalized attitudes and their self-reported scores on the CLEFT-Q was documented along with any resultant modifications to their care plan.

Results: Seventy patient visits were observed; the mean patient age was 12.7 years (range, 8 to 19 years). Forty-one patients (59%) had cleft lip and palate/alveolus and 29 (41%) had isolated cleft palate. Discordance was observed in 36% of visits and in 9.2% of specific domains assessed. Highest discordance rates were observed in domains of psychosocial function (12.5%), speech function/distress (11.6%), and lips/lip scar appearance (11.6%). No age group or sex was associated with increased discordance. Integration of CLEFT-Q results altered the assessment and plan in 11 visits (16%).

Conclusion: The CLEFT-Q provides clinically relevant insight into patient perspectives that are not captured by routine interview and examination alone, and regularly leads to a change in the management plan.

Background: Hypertrophic scars (HSs) cause functional impairment and cosmetic deformities following operations or burns (30% to 94%). There is no target therapy yet because the pathogenesis of HS progression is not well known. In tissue fibrosis, abnormal up-regulation of zinc finger E-box binding homeobox 1 (ZEB1) is an important cause for extracellular matrix (ECM) overexpression, which is the main molecular change in HSs. The authors hypothesized that ZEB1 knockdown inhibits HS formation.

Methods: ZEB1 expression in human HS and transforming growth factor-β1-induced fibroblasts were identified by polymerase chain reaction (PCR) and Western blotting. ZEB1 was knocked down by small interfering RNA in HS fibroblasts (HSFs) and the mouse HS model (C57/BL6 male mice aged 8 to 12 weeks). After 8 hours of transfection, HSFs were subjected to PCR, Western blotting, and Cell Counting Kit-8 apoptosis, migration, and contraction assays. Mouse HSs were analyzed by hematoxylin and eosin staining, PCR, and Western blotting after 56 days.

Results: ZEB1 was up-regulated in HS tissue (2.0-fold; P < 0.001). ZEB1 knockdown inhibited HSF activity (0.6-fold to 0.7-fold; P < 0.001); the expression of fibrotic markers (0.4-fold to 0.6-fold; P < 0.001); and β-catenin, cyclinD1, and c-Myc expression (0.5-fold; P < 0.001). In mouse HS models, HS skin thickness was less (1.60 ± 0.40 mm versus 4.04 ± 0.36 mm; P < 0.001) after ZEB1 knockdown.

Conclusions: ZEB1 knockdown inhibits HS formation both in vitro and in vivo. However, this is an in vitro mouse model, and more validation is needed.

Clinical relevance statement: The discovery of ZEB1 as a mediator of HS formation might be a potential therapeutic target in HS treatment.

Background: Extracranial vascular malformations affect vessel inflammation, clotting, and ischemia. However, the relationship between extracranial vascular malformations and myocardial infarction (MI) or stroke has not been fully elucidated. Limited studies have investigated the association between extracranial vascular malformations and cardiovascular diseases.

Methods: A total of 48,701 patients with extracranial vascular malformations and a control cohort of 487,010 age- and sex-matched participants from the Korean National Health Insurance database were included. The incidence and risk of MI, ischemic stroke (IS), and hemorrhagic stroke (HS) between participants with extracranial vascular malformations and the control cohort was compared.

Results: After adjusting for other cardiovascular disease risk factors, the adjusted hazard ratios (aHRs) for venous malformations, capillary malformations (CMs), arteriovenous malformations (AVMs), and lymphatic malformations in patients with acute MI were 1.25 (CI, 1.04 to 1.50), 1.41 (CI, 1.24 to 1.61), 1.68 (CI, 1.18 to 2.37), and 1.40 (CI, 1.31 to 1.48), respectively. For IS, the aHRs were 1.55 (CI, 1.35 to 1.77), 1.92 (CI, 1.74 to 2.11), 1.13 (CI, 0.78 to 1.64), and 1.51 (CI, 1.44 to 1.58), respectively. For HS, the aHRs were 1.51 (CI, 1.12 to 2.05), 5.63 (CI, 4.97 to 6.38), 2.93 (CI, 1.82 to 4.72), and 1.34 (CI, 1.20 to 1.50), respectively.

Conclusions: Independent of cardiovascular risk factors, extracranial vascular malformations were associated with an increased risk of MI, IS, and HS. For patients with CMs and AVMs, intracerebral hemorrhage risk was particularly high, accounting for 563% and 293%, respectively. Therefore, even in patients with extracranial CMs or AVMs, performing diagnostic evaluations for cerebral AVMs and using measures to prevent intracerebral hemorrhage are crucial.

Clinical question/level of evidence: Risk, II.

Background: Preservation rhinoplasty techniques continue to evolve. Suture tip-plasty with minimal resection and grafting, lateral crural tensioning, minimal excision from the lateral crura, dorsal preservation, subperichondrial dissection, and preservation of the ligaments have become the milestones of modern rhinosurgery. However, every time the dorsal frame is modified by means of rasping, shaving, or osteotomy, or the nasal tip is structured using grafts, surgeons are essentially applying structural concepts to their technique. The term "hybrid rhinoplasty" seems to include a more appropriate definition of this approach.

Methods: The authors performed a retrospective analysis of the medical records of patients who underwent primary septorhinoplasty using the low strip unifying hybrid rhinoseptoplasty concept from December of 2019 to June of 2022. Patient functional satisfaction and cosmetic satisfaction were evaluated using the Rhinoplasty Health Inventory and Nose Outcome scale.

Results: All reported procedures had low revision rates with good cosmetic and functional outcomes.

Conclusions: Tailoring the surgical technique is essential in rhinoplasty. The authors present a new technical paradigm to help surgeons choose the best approach for dorsal preservation surgery.

Clinical question/level of evidence: Therapeutic, IV.

Background: The Nasal Obstruction Symptom Evaluation (NOSE) and the Functional subscale of the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS-O) are widely used patient-reported outcome measures to measure functional outcomes of rhinoplasty. However, as different instruments produce scores on different metrics, results of these instruments cannot be linked directly, thus hindering comparison and aggregating of rhinoplasty outcome data from practices using either instrument. The aim of this study was to develop and validate crosswalks between the NOSE and the SCHNOS-O.

Methods: In a sample of 552 rhinoplasty patients who completed both instruments, the NOSE and SCHNOS-O scales were co-calibrated onto a common interval-scaled metric using Rasch analysis. Separate Rasch models were run per instrument, and the latent constructs were estimated using the calibrated item parameters. By anchoring original patient-reported outcome measure scores of both instruments to this Rasch computed measurement scale, the scores of both instruments were linked. A second independent sample was used to validate the created crosswalks.

Results: Total scores on the NOSE and SCHNOS-O were strongly correlated. The Rasch-based co-calibration of the NOSE and SCHNOS-O items resulted in a model that adequately fitted the data. Back-and-forth crosswalk tables were created from the NOSE to the SCHNOS-O. For patients with moderate nasal obstruction, predicted SCHNOS-O scores were slightly higher for a given level of the NOSE. Intraclass correlation coefficients between predicted and actual scores were 0.93 for both directions, indicating adequate agreement for group-level comparisons.

Conclusions: This study developed and validated Rasch-based crosswalks from the NOSE to the SCHNOS-O and vice versa. The provided crosswalks enhance comparison and harmonization of functional rhinoplasty outcomes.

Background: An increasing number of women are undergoing breast implantation for cosmetic purposes or for reconstructive purposes after breast excision. The surface morphology of the breast implant is a key factor associated with the induction of capsule contraction. The effect of surface morphology on the inflammatory response after implant insertion remains unclear, however. The authors conducted comparative analyses to determine the effect of the textured and smooth surface morphology of silicone sheets.

Methods: Each type of silicone sheet was inserted into the subcutaneous pocket below the panniculus carnosus in C57BL/6 mice and mice with genetic disruption of CARD9 , Dectin-1 , Dectin-2 , or Mincle . The authors analyzed collagen fiber capsule thickness, histologic findings, and macrophage inflammatory response, including transforming growth factor (TGF)-β synthesis.

Results: The authors found that textured surface morphology contributed to the formation of collagen fiber capsules and the accumulation of fibroblasts and myofibroblasts, and was accompanied by the accumulation of TGF-β-expressing macrophages and foreign-body giant cells. CARD9 deficiency attenuated collagen fiber capsule formation, macrophage responses, and TGF-β synthesis, although the responsible C-type lectin receptors remain to be clarified.

Conclusion: These results suggest that CARD9 may have a strong impact on silicone sheet morphology through the regulation of macrophage responses.

Clinical relevance statement: Silicone breast implants have been widely used for postmastectomy and cosmetic augmentation mammaplasty breast reconstruction. The authors sought to elucidate the surface morphology of the breast implant as one of the key factors associated with the formation of collagen fiber capsules.

Clinical question/level of evidence: Therapeutic, V.