Plastic and reconstructive surgery最新文献

Background: Various surgical methods have been developed for treating velopharyngeal insufficiency (VPI); however, the choice of surgical treatment is controversial. The pharyngeal flap, which is commonly used, has a high success rate but frequently leads to airway complications. Furlow double-opposing Z-plasty (DOZ) does not deform the velopharyngeal port; therefore, it is expected to show good speech outcomes while reducing airway complications if an appropriate indication is noted. This study aimed to identify indications for DOZ in cases of VPI after palatoplasty.

Methods: Nonsyndromic patients who underwent palatoplasty were prospectively followed from 2008 to 2016, and those diagnosed with VPI were treated with DOZ. Preoperative facial computed tomography (CT) and postoperative nasometric assessment results were examined. Surgical indication was set based on a 30% threshold value for postoperative nasalance.

Results: Comparing the preoperative CT measurements of both groups, high need ratio (NR), wide width of the nasopharynx (WNP), and long velopharyngeal depth (VPD) were contributing factors to VPI occurrence ( P < 0.05). Analyzing preoperative CT and postoperative speech evaluation results, a linear relationship was observed between preoperative NR, WNP, and VPD and postoperative nasalance. In cases where NR was less than 0.81, WNP was less than 27.64 mm, and VPD was less than 20.34 mm, DOZ showed favorable outcomes ( P < 0.05).

Conclusions: Preoperative CT evaluation should be performed in patients with VPI. When WNP, VPD, and NR values are small, DOZ can achieve sufficient correction of VPI and reduce the risk of airway complications. In cases where the indication range is exceeded, the pharyngeal flap is considered.

Clinical question/level of evidence: Risk, III.

Background: People with diabetic foot ulcers (DFUs) are at risk of major amputation, which is associated with a high mortality rate (exceeding 50% at 5 years) and reduced quality of life. The authors hypothesized that flap reconstruction of DFUs improves patient outcomes in comparison with standard treatment modalities, including major amputation.

Methods: MEDLINE, Embase, the Cochrane Library, and gray literature were searched on February 9, 2022. Comparative and single-arm studies reporting outcomes of DFUs treated with local, regional, or free flaps that included function, limb loss, mortality rates, and flap failure rates were included. Risk of bias was assessed, and meta-analysis of proportions was performed.

Results: A total of 3878 records were retrieved, of which 45 met the inclusion criteria, including the records of 1681 patients who underwent flap reconstruction of DFUs. Free flaps were most commonly performed ( n = 1257 [72%]). Only one study used a verified functional outcome measure. At 12 months, the mortality rate was 6.35% (95% CI, 3.89% to 10.20%), the limb loss rate was 11.39% (95% CI, 7.02% to 17.96%), and the free flap failure rate was 9.95% (95% CI, 8.19% to 12.05%). All studies were at high risk of bias. A comparative meta-analysis of interventions was not performed because of study method and outcome heterogeneity.

Conclusions: There is short-term evidence that flap reconstruction (including microsurgical transfer) has low mortality, limb loss, and flap failure rates. However, there are limited high-quality comparative studies, and uncertainty remains regarding the outcome of DFU flap reconstruction in comparison to other treatments.

Background: The aim of this study was to investigate whether using an innervated vascularized iliac bone flap could effectively prevent bone resorption and maintain sensory function in the lower lip.

Methods: In the innervated group, the deep circumflex iliac artery and recipient vessels were anastomosed, with simultaneous microanastomosis of ilioinguinal nerve, mental nerve, and inferior alveolar nerve. Conversely, the control group underwent solely vascular anastomosis. Computed tomography was used to assess bone quality. Sensory recovery of the lower lip was recorded using 2-point discrimination and current perception threshold testing.

Results: The study comprised a total of 40 subjects, with each group accounting for 20 participants, equally distributed in terms of gender. Hounsfield unit loss was significantly lower in the innervated group (13.26% ± 8.65%) as compared with the control group (37.98% ± 8.60%) ( P < 0.001). Moreover, 2-point discrimination values were lower in the innervated group (15.11 ± 8.39 mm) when compared with the control group (21.44 ± 7.24 mm) ( P = 0.02). The current perception threshold values for the innervated group were 176.19 ± 31.89, 64.21 ± 19.23, and 42.29 ± 18.96 at 2 kHz, 250 Hz, and 5 Hz, respectively, whereas in the control group, the current perception threshold values were 204.47 ± 36.99, 82.26 ± 27.29, and 58.89 ± 25.38 at 2 kHz, 250 Hz, and 5 Hz ( P = 0.02, P = 0.02, and P = 0.03, respectively).

Conclusion: The innervated vascularized iliac bone flap represents a safe and effective novel approach to preserving lower lip sensation and preventing bone resorption through functional mandibular reconstruction.

Clinical question/level of evidence: Therapeutic, I.

Background: This study explored the surgical management and reconstruction options for augmented breasts in the context of breast conservation therapy (BCT) for breast cancer. The authors hypothesized that there would be no difference in the rates of complications, revisions, or patient satisfaction in patients who maintained their breast augmentation versus those who had their implants removed in the context of BCT.

Methods: The authors conducted a retrospective review of 142 patients who underwent BCT at a single center from March of 2016 to March of 2022. The study included patients who had a preexistent cosmetic augmentation at the time of breast cancer diagnosis and BCT. Patient demographics, clinical and treatment characteristics, breast implant details, reconstructive technique, complications, and revisions were recorded. Patient-reported outcomes were assessed using the BREAST-Q BCT module.

Results: Ninety-three patients (65.5%) chose to maintain their implants, whereas 49 (34.5%) elected to have them removed during BCT. Patients with submuscular implants were more likely to maintain their implants. Oncoplastic mastopexy was associated with higher complication rates, particularly in patients opting for implant downsizing. However, multivariate logistic regression did not identify implant management strategy as an independent predictor for complications or revisions. Surgical-site infection was the only predictor of implant explantation. Patient-reported outcomes did not differ significantly between the different implant management cohorts.

Conclusions: This study demonstrates that maintaining breast implants during BCT does not increase the risk of complications or revisions. Overall, BCT in augmented women was found to be a safe approach, with high patient satisfaction.

Clinical question/level of evidence: Risk, III.

Summary: Frontalis suspension is the preferred approach for blepharoptosis with compromised levator function. Various studies have explored the use of different materials or material shapes for performing this procedure; however, a limited number discuss the specifics of skin incisions. Given that blepharoplasty demands not only functional but also aesthetic results, the authors applied an infrabrow incision, a technique commonly used in cosmetic surgery. This study, the first report involving a series of blepharoptosis cases treated using this technique, explores its viability as a promising alternative to traditional frontalis suspension. This technique was used in 7 consecutive patients exhibiting poor levator function who were treated at the University of Tokyo between September of 2019 and February of 2022. A retrospective analysis was conducted on clinical photographs and charts. In 1 representative case, visual field angle and frontal muscle tone were also measured. The average duration of postoperative follow-up was 9 months. In all cases, the frontalis muscle was adequately exposed to allow suspension through the infrabrow approach. Significant improvements were observed in the marginal reflex distances without effort from -1.9 to 2.1 mm ( P = 0.0027) and marginal reflex distances with effort from 0.0 to 5.4 mm ( P < 0.0001). Complications included a hematoma ( n = 1), eyelash entropion ( n = 1), transient sensory loss of the forehead ( n = 1), and transient dry eye ( n = 3). The infrabrow incision is a good alternative for frontalis suspension owing to its capacity to offer a broad surgical field, provide effective access to the frontalis muscle, and facilitate excess skin excisions without resulting in conspicuous scarring.

Clinical question/level of evidence: Therapeutic, IV.

Background: The authors hypothesized that the 3-ligament tenodesis (3-LT) procedure is still sufficient-even in scapholunate advanced collapse (SLAC) cases-to reduce pain and improve wrist function. The authors compared patient-reported outcomes of scapholunate interosseus ligament (SLIL) injury patients with SLAC, to SLIL injury patients treated with 3-LT, and then to patients who underwent proximal row carpectomy (PRC), as a control group.

Methods: The authors included all patients with a traumatic SLIL injury and associated SLAC components treated with 3-LT and completed patient-rated wrist evaluation (PRWE) questionnaires preoperatively and at 12-month follow-up. First, the authors compared matched patients with SLIL injury and SLIL injury with SLAC, stage 1 to 3, who received 3-LT. Second, the authors compared patients who received 3-LT with patients who underwent PRC, while having SLAC stage 2 or 3.

Results: The authors compared 51 patients with SLAC to 95 patients with SLIL injury who had a 3-LT procedure, and 10 3-LT patients were compared with 18 patients undergoing PRC, given SLAC stage 2 or 3. In both analyses, the PRWE scores had significantly improved in all groups; however, no significant differences in PRWE were found between 3-LT in SLIL injury and SLIL injury with SLAC (6.9 points; 95% CI, -14.92 to 1.22; P = 0.096) and between 3-LT and PRC, given SLAC stage 2 or 3, 15.1 points (not enough power).

Conclusions: There is no difference in PRWE between matched SLIL injury patients with or without degenerative changes treated with a 3-LT. Therefore, the 3-LT procedure seems to be a viable treatment option for patients with early-stage SLAC wrist.

Clinical question/level of evidence: Therapeutic, III.

Background: Ischemic necrosis in the distal portion of a flap is a challenging complication in plastic surgery. The authors hypothesized that a novel hybrid flap preconditioning (HFP) device combining foam-mediated external suction and nonsurgical delay can promote skin flap survival better than surgical delay.

Method: Twenty-eight mice were divided into 4 groups: a control group, in which a 4 × 1.5-cm dorsal flap was made with no preconditioning; a surgical delay group, in which surgical delay occurred 7 days before flap elevation; a foam-mediated external suction (FMES) group, in which foam-mediated external suction at -100 mm Hg was used 5 hours a day for 6 days, and the flap was elevated on the seventh day; and a hybrid flap preconditioning (HFP) group, in which silicone strips were applied along the contour of the foam interface. The same negative-pressure protocol was used as in the FMES group. Seven days after flap elevation, macroscopic, histologic, and Western blot analyses were performed.

Results: The flap survival rate was 46.25% (8.12%) in the control group, 68.72% (7.00%) in the surgical delay group, 57.03% (8.17%) in the FMES group, and 80.66% (3.27%) in the HFP group. Immunohistologic analysis of CD31 + cells in the distal end of viable tissue procured 7 days after flap elevation showed significantly higher angiogenesis in the surgical delay and HFP groups. Western blot results showed an increased expression of vascular endothelial growth factor in the surgical delay and HFP groups.

Conclusions: The authors developed and fabricated a novel HFP device combining foam-mediated external suction and nonsurgical delay. The concept of HFP has proved to promote flap survival better than surgical delay.

Clinical relevance statement: This study presented an innovative noninvasive method of flap preconditioning, which has been demonstrated to be superior to surgical delay in a murine model and holds promise for potential application in clinical settings.

Background: Gynecologic cosmetic surgery and rejuvenation surgery have become increasingly popular, with growing demand for vaginal surgery to address vaginal laxity. Follow-up data on the effectiveness of these procedures remain limited. The authors conducted a retrospective study to investigate the effects of transvaginal posterior levatorplasty combined with perineoplasty on vaginal rejuvenation.

Methods: The study included 45 patients who underwent transvaginal posterior levatorplasty combined with perineoplasty between July of 2020 and May of 2022. Patient characteristics before operation, at baseline, and 3, 6, and 12 months postoperatively, and questionnaires on patient symptoms, quality of life, and sexual function, including the Vaginal Laxity Questionnaire and Female Sexual Function Index, were evaluated. Pelvic ultrasound imaging was performed preoperatively and 3 months postoperatively.

Results: Mean vaginal capacity index and vaginal laxity scores were different at baseline and 6 and 12 months postoperatively ( P < 0.01). Female sexual function, including libido, sexual arousal, lubrication, orgasm, sexual satisfaction, and pain levels, were significantly improved (preoperative, 21.68 ± 4.15; 6 months postoperatively, 26.88 ± 2.44; 1 year postoperatively, 29.97 ± 2.10; P < 0.01). Symptoms of stress urinary incontinence and recurrent vaginitis were improved in 78.6% and 90.5% of patients, respectively. On pelvic floor ultrasound, retrovesical angle, urethral rotation angle, levator hiatus, and bladder neck distance were significantly different preoperatively and 3 months postoperatively ( P < 0.01). Overall satisfaction was 93.3% at 12 months postoperatively.

Conclusions: Transvaginal posterior levatorplasty combined with perineoplasty is effective for the improvement of patient symptoms, quality of life, sexual function, stress urinary incontinence, and postnatal constipation. Further research on the underlying mechanisms is required.

Clinical question/level of evidence: Therapeutic, IV.