Plastic and reconstructive surgery最新文献

Prune Belly Syndrome (PBS) is a rare congenital disorder characterized by severe abdominal wall muscle deficiency, leading to significant impairment of respiratory, urinary, and gastrointestinal function. Despite numerous reconstructive attempts, no technique has achieved full functional restoration of the anterior abdominal wall. This paper introduces a novel dynamic reconstructive approach using bilateral pedicled musculo-fascial Vastus Lateralis (VL) flaps for functional abdominal wall reconstruction in PBS. Unlike traditional abdominoplasty-based procedures that mainly address cosmetic deformity, this method focuses on restoring true muscle dynamics and physiological function. The technique involves harvesting innervated, vascularized VL flaps from both thighs and transposing them to the anterior abdominal wall through a subcutaneous tunnel while preserving their neurovascular pedicles. The muscles are anchored to the costal arch superiorly and the pubic symphysis inferiorly, effectively recreating the functional vector of the rectus abdominis. This configuration enables dynamic contraction of the abdominal wall and reinstates the ability to generate intra-abdominal pressure required for coughing, defecation, and postural control. Follow-up assessment, including electromyography (EMG) and motor testing, confirmed active muscle contraction and marked improvement in core function. Patients demonstrated restored abdominal wall activity, enhanced motor abilities, and reduced symptoms related to ineffective intra-abdominal pressure, such as constipation and respiratory infections. This study presents the first reproducible surgical solution achieving both anatomical reconstruction and functional reanimation of the abdominal wall in PBS. The described technique offers a transformative step in pediatric reconstructive surgery, combining microsurgical precision with physiological restoration to improve long-term quality of life.

Background: Correction of prominent upper pole of ear is challenging, with high recurrence rates. Conventional otoplasty often fails to address the inferior crus, a key anatomical determinant of prominence. This study introduces a surgical technique targeting the inferior crus, a novel Inferior Crus Morphological Grading System (ICMGS) for diagnosis, and a new "upper pole declination angle" for objective assessment.

Methods: In this retrospective comparative study, 120 ears treated with a new technique were compared to 120 ears in a historical control group (traditional method). The new technique combines superior auricular muscle release, multi-loop inferior crus suturing, conchal reduction, and cartilage graft reinforcement. Outcomes were assessed via objective photogrammetry (including the upper pole declination angle) and blinded subjective scoring.

Results: The new technique demonstrated statistically superior results, with significantly greater reductions in upper pole declination angle, L1, and L2 distances (p<0.001). Blinded aesthetic scores were also significantly higher (p<0.001). The technique's efficacy correlated directly with the preoperative ICMGS grade (p<0.001). The revision rate was lower in the new technique group (3.3% vs. 8.3%).

Conclusions: Anatomical correction of the inferior crus is a critical and effective strategy for prominent upper pole. The proposed technique, along with the ICMGS and upper pole declination angle, provides a reliable and durable solution with superior objective and subjective outcomes and a lower revision rate compared to traditional methods.

Background: A Divided eyelid nevus is a rare congenital condition that poses complex reconstructive challenges. This study reports our experience with single split-flaps for medium and large-sized lesions, complemented by a systematic review of flap-based techniques.

Methods: We retrospectively analyzed 26 patients treated between 2005 and 2024. Eleven patients with broad foreheads underwent reconstruction using superficial temporal artery frontal branch (STA-Fbr)-based flaps, and fifteen underwent reconstruction using distally based brachial artery perforator (dBAP) flaps. Intraoperative indocyanine green angiography (ICGA) was used for vessel mapping, flap splitting, and perfusion assessment. Depending on medial canthus involvement, the flaps were split distally in a fish-mouth or window pattern to enable simultaneous reconstruction of both eyelids. A systematic review was conducted on August 12, 2024, across four major databases.

Results: Six medium and five large lesions were reconstructed using STA-Fbr-based flaps, whereas six medium and nine large lesions were reconstructed using dBAP flaps. The mean tissue expansion periods were 5 and 6 months, respectively. ICGA accurately guided flap splitting and confirmed adequate perfusion. All STA-Fbr-based and 12 dBAP flaps were split in a fish-mouth pattern, while the remaining dBAP flaps were split in a window pattern. All flaps survived without venous congestion or necrosis. The systematic review identified 27 studies supporting the reliability of pre-expanded forehead and medial arm flaps for large lesions.

Conclusions: The single split-flap technique using pre-expanded STA-Fbr-based or dBAP flaps under ICGA guidance is a reliable approach for the simultaneous reconstruction of both eyelids in medium and large lesions, achieving favorable functional and aesthetic outcomes.

Background: Various complications can be the reason for loosening from peri oral attachment after a functioning muscle transfer such as suture failure, tearing of the transplanted muscle at the attachment or a tear in the attachment itself. All these can lead to revisional surgery, which is reported as high as 39%. Although SMAS(superficial muscular aponeurotic system) is the most frequently used layer, the primary authors has encountered multiple unsatisfactory results using SMAS as the sole attachment layer. Main purpose of the study is to investigate biomechanical properties of distinct layers around the mouth by exposing various tissue blocks harvested from fresh cadaver heads to a load until failure system.

Methods: A total of 51 distinct 1 cm² tissue blocks, consisting of either submucosa, SMAS, SMAS-buccinator complex or a combination of all the mentioned layers (ergo full thickness) were taken from perioral region of 6 different fresh cadaver hemifaces and placed in a servo-hydraulic testing machine using a load-until-failure model. Vector of the applied load was similar to an in vivo scenario.

Results: SMAS group had the least ultimate load capacity and worst stiffness among all groups. Full thickness group resisted higher ultimate loads and both full thickness and submucosa group had less extension at ultimate load compared to the remaining two.

Conclusion: Contrary to common practice, SMAS had the least favorable attributes for a stable attachment for muscle transfer; full thickness bite can a reliable option for secure attachment while accompanied by attachment to different layers for nuanced outcomes.

Background: The trans-axillary reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) technique demonstrates advantages in operative efficiency and cosmetic outcomes. This large-scale study evaluated its surgical safety and identified associated risk factors.

Methods: We retrospectively analyzed clinical data from patients undergoing R-E-NSM between May 2020 and September 2023. Multivariable logistic regression identified independent risk factors for complications.

Results: The analysis included 931 R-E-NSM procedures in 727 patients. Breast reconstruction was performed in 618 (85.00%) cases. The overall complication rate was 14.31%, with major complications occurring in 2.20% of cases. A breast cup size of D or larger was an independent risk factor for major complications (OR, 16.00; 95% CI, 1.89-135.2; P = 0.01). Independent risk factors for any complication included breast ptosis (Grade I: OR, 1.96; 95% CI, 1.13-3.43; P = 0.02; Grade II: OR, 1.77; 95% CI, 1.01-3.90; P = 0.046) and adjuvant chemotherapy (ACT) (OR, 1.76; 95% CI: 1.05-2.96; P = 0.03). Independent risk factors for surgical site infection were prepectoral implant-based breast reconstruction (IBBR) (OR, 4.62; 95% CI, 1.04-20.59; P = 0.045), dual-plane IBBR (OR, 6.87; 95% CI, 1.55-30.45; P = 0.01), and ACT (OR, 2.15; 95% CI, 1.08-4.28; P = 0.03). Late cosmetic revisions occurred in 1.54% of patients. At a median follow-up of 30.20 months, locoregional recurrence and distant metastasis rates were both 1.00%.

Conclusions: R-E-NSM is a safe option for treating benign and malignant breast diseases. Special consideration is warranted for patients with larger breast volume (cup size ≥D). Long-term comparative studies are needed to further validate its role.

Background: The lumbar artery perforator (LAP) flap has emerged as a reliable option for autologous breast reconstruction in patients lacking suitable abdominal donor tissue. This study presents a comprehensive 7-year institutional analysis of 300 LAP flaps, examining patient selection, surgical outcomes, temporal trends, and patient-reported outcomes.

Methods: A retrospective review of all LAP flap breast reconstructions between December 2018 and May 2025 was performed. Patients were categorized by reconstruction type: unilateral, bilateral, and stacked LAP flaps. Complications, operative characteristics, and BREAST-Q outcomes were analyzed. Bilateral LAP flaps were further stratified into four temporal cohorts to assess changes over time.

Results: A total of 300 LAP flaps were performed in 162 patients, including 107 bilateral, 21 unilateral, 31 bilateral stacked, and 3 unilateral stacked reconstructions. Overall complication rates for non-stacked LAP flaps decreased from 30.2% in 2019 to 8.8% by 2024-2025, despite a more than threefold rise in annual case numbers. BREAST-Q scores demonstrated sustained improvements across all domains, including satisfaction with breasts, psychosocial and sexual well-being, and physical well-being of the chest. Stacked LAP flaps were associated with significantly higher complication rates (45.2-66.7%) compared to standard LAP flaps (23.4-28.6%, P = 0.043), particularly in patients with elevated BMI and diabetes.

Conclusions: As microsurgical experience with LAP flaps grows, institutional complication rates markedly decline over time, making LAP flaps a safe and effective option for autologous breast reconstruction. LAP flaps yield durable reconstructive outcomes and sustained improvements in patient-reported satisfaction and quality of life.

Background: The combination of deep inferior epigastric artery perforator (DIEP) free flap and implant has been reported as a safe option for breast reconstruction in patients with insufficient abdominal donor tissue. We present a single-surgeon 10-year experience with hybrid reconstruction.

Methods: We performed a retrospective review of patients who underwent hybrid breast reconstruction with DIEP and implant by a single surgeon at a single institution between 2014-2024. Patient characteristics and operative factors were analyzed for association with flap failure.

Results: 91 patients (153 breasts) were included. Success rate following initial (simultaneous or delayed) implantation and after implant exchange were 98% and 96.1%, respectively. Univariate analyses showed significantly larger mean final implant size in the failed DIEP group (362.50±228.05 mL) compared to the successful reconstruction group (219.20±101.24 mL), with OR of 1.42 (95% CI: 1.149-1.76, p-value = 0.002) per 50 mL increase of the implant size.

Conclusions: Hybrid DIEP with implant reconstruction is a safe procedure. Placement of a greater volume implant is associated with flap failure. Implant exchange for upsize also possesses a risk of flap failure.

Background: Facial asymmetry is often overlooked in evaluations of nasal function and aesthetics, despite its potential impact on assessments in facial plastic surgery.

Objective: This study aims to utilize AI tools to identify facial asymmetry metrics that correlate with both nasal function and aesthetic measures evaluated by pre-op SCHNOS Scores.

Methods: Two facial landmark detection models were applied to frontal plain facial images of 1,523 patients to extract 506 fiducial points. From these, over 64 million facial elements were computed, including point-to-point and point-to-line distances. Then asymmetry indexes were calculated based on each element with its mirrored counterpart. Finally, Spearman correlation coefficients were used to assess associations between these asymmetry metrics and 13 outcome scores.

Results: Facial elements correlated with SCHNOS-O demonstrated modest but statistically significant Spearman correlations (0.185-0.224, p < 10⁻¹¹), particularly those capturing vertical facial height differences relative to a horizontal reference line between the nasal tip and ear base. No meaningful correlations were observed with SCHNOS-C scores.

Conclusion: These findings suggest vertical midfacial asymmetry may impact nasal function, whereas facial asymmetry has minimal influence on patients' perception of nasal aesthetics. The study also underscores the potential of AI-based facial analysis as a valuable tool in rhinoplasty evaluation.

Background: Isolated congenital muscular pseudohypertrophy of the upper limb is a very rare anomaly. With our case series spanning twenty years, we aim to illustrate the pathological anatomy associated with this rare disorder and present a surgical framework in the operative treatment of this elusive condition.

Methods: Patients presenting at two institutions were retrospectively reviewed. Exclusion criteria include syndromes (e.g. CLOVES) or isolated macrodactyly. Patients who presented with worsening deformities such as increasing metacarpophalangeal joint ulnar deviation, hyperabduction of thumb with widening of webspace affecting grasp or wrist deformities were recommended surgery. Surgical procedures include removal of aberrant muscles, rebalancing procedures or osteotomies.

Results: A total of 25 patients were reviewed, of which 18 underwent surgery and 13 attended postoperative review. The median age was 7.5 years, and mean follow-up period was 42 months. Radial abduction improved from 54° to 36°, and ulnar deviation improved from 39° to 13°. All patients regained postoperative thumb opposition to the little finger, a function that had been previously lost. However, only 8/13 could oppose the thumb to the index finger postoperatively. Surgical findings revealed interesting additional layers of muscles which are unnamed, with some of these accounting for the deformities and others for bulk. The predominant finding was that of extra muscles rather than hypertrophied muscles.

Conclusions: This is one of the largest reported series of congenital muscular pseudohypertrophy of the upper limb. We developed a scoring system for severity and an accompanying algorithm to guide when to offer surgery for moderate or severe deformities. These new muscle morphologies may shed light on evolutionary developmental biology pathways, allowing their safe removal during surgery.Level of evidence: IV.