Plastic and reconstructive surgery最新文献

Background: Dorsal preservation techniques balance hump reduction with mid-vault support. Foundation techniques (impaction) lower the dorsal hump without reshaping it, whereas surface modulation can compromise vault support. We propose an intermediate approach-boomerang mid-septal excision with intermediate osteotomies-that straightens the dorsum while preserving the keystone area and dorsal aesthetic lines.

Materials and methods: A retrospective case series of 50 patients who underwent rhinoplasty between July 2021 and march 2024 using the following operative technique: (1) boomerang-shaped mid-septal cartilage excision, dividing the septum into anterior and posterior segments; (2) osteotomy or ostectomy of the nasal bones at the nasomaxillary suture in a pre-designed pattern; (3) sliding caudal advancement of the anterior septal flap to straighten the osteocartilaginous hump; and (4) fixation of the bone and cartilaginous segments. Clinical examinations and digital photographs were used to document progression, stability of results, and complications.

Results: At a mean 18-month follow-up, dorsal straightening was maintained in 38/50 (76%); no defects or irregularities were noted at the intermediate bony work.

Conclusion: The proposed technique may, in selected cases: 1) facilitate single-unit dorsal straightening with limited soft-tissue dissection for a smoother contour; 2) broaden the bony hump morphologies amenable to preservation; 3) provide a caudally advanced septal flap for nasal lengthening or tip support when indicated; 4) supply a boomerang cartilage graft for adjunctive maneuvers; and 5) allow stabilization of the straightened dorsum through suture fixation of both bony and cartilaginous segments.

Introduction: Targeted Muscle Reinnervation (TMR) can prevent and treat neuropathic pain in amputees, but the degree of success varies. This study developed a Machine Learning (ML) model to predict the likelihood of sustained pain mitigation following primary and secondary TMR based on patient characteristics.

Methods: Patients who underwent TMR at a tertiary care center (2017-2024) were included. Patients were categorized as achieving good or poor pain outcomes based on predefined criteria: ≥3/10-point reduction (Numeric Rating Scale) for secondary TMR, or pain scores ≤3/10 for ≥3 months for primary TMR. Three ML architectures (lasso logistic regression, random forest classifier, and relevance vector machine (RVM)) were tested. Model performance was evaluated using area under the receiver operating characteristic (AUROC) curve; feature importance was quantified using Shapley additive explanations (SHAP).

Results: In total, 77 primary TMR and 101 secondary TMR patients were included (median follow-up: 2.0 years). The RVM model achieved test prediction accuracy scores of 0.74±0.12 for both primary and secondary TMR, with AUROC scores of 0.78±0.13 and 0.80±0.05, respectively. For primary TMR, pre-operative opioid use, male sex, and history of depression showed strong negative impacts. For secondary TMR, pre-operative smoking, elevated pain scores, and history of anxiety were strong negative predictors. The model significantly outperformed traditional statistical approaches.

Discussion: This novel custom ML model achieved strong predictive capability for TMR outcomes, demonstrating proof of concept of a practical tool for surgical planning and patient selection. The identification of several key modifiable risk factors suggests opportunities for pre-operative optimization to improve surgical outcomes.

Background: Adjuvant anticancer agents are often prescribed to patients with breast cancer to reduce recurrence risk and improve outcomes. Many patients take these medications during primary and staged breast reconstruction. This study presents a review of the literature on adjuvant anticancer medications and whether, based on side effects and risks, they should be held for elective, medically necessary reconstructive procedures. The authors provide expert multidisciplinary consensus recommendations for commonly prescribed agents.

Methods: Following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the authors queried 3 databases for relevant key words (eg, "breast reconstruction" AND "anticancer agent"). Inclusion criteria encompassed studies on anticancer agents and breast reconstruction; non-English-language articles and reviews were excluded. Perioperative recommendations were developed on the basis of the review and expert consensus.

Results: The query identified 1188 articles, which was narrowed to 19 included articles involving 5793 patients. Included studies discussed tamoxifen ( n = 18), aromatase inhibitors ( n = 8), trastuzumab ( n = 2), or pertuzumab ( n = 1). No study examined gonadotropin-releasing hormone agonists or pembrolizumab. Based on the review and consensus, the authors created guidelines on when to hold medications preoperatively. Expert consensus indicated that most medications do not need to be held, although preoperative laboratory tests evaluating leukocytes or platelets are advised in some cases.

Conclusions: Plastic surgeons frequently treat patients who are taking anticancer agents. Rapid research advancements present challenges to understanding the impact of anticancer agents on perioperative risk and surgical outcomes. The guidelines in this article provide an update on medication management and perioperative counseling for patients undergoing primary or revision breast reconstruction procedures.

Background: Recent antibiotic use can disrupt the human microbiota, leading to dysbiosis, which alters microbial composition and function. Despite being a clean procedure, tissue expander (TE)-based breast reconstruction is associated with surgical site infection (SSI) rates as high as 30%, suggesting the influence of various factors. This study was performed to investigate whether previous antibiotic use is associated with an increased risk of SSIs in patients undergoing TE-based breast reconstruction.

Methods: The TriNetX database was queried to identify patients who underwent TE-based breast reconstruction. Patients were classified into an exposed group, who received antibiotics within 30 days before surgery, and a control group, who did not. Propensity score matching was performed for infection risk factors. The primary outcome was SSIs. Secondary outcomes included wound dehiscence, emergency department visits, antibiotic use, and TE removal. These outcomes were assessed at 30, 60, and 90 days after surgery.

Results: After matching, each group included 1383 patients. At 30 days after surgery, patients who received antibiotics within 30 days before TE-based breast reconstruction had an increased risk of SSI (risk ratio [RR], 3.91 [ P < 0.001]), wound dehiscence (RR, 2.26 [ P = 0.002]), antibiotic use (RR, 2.38 [ P < 0.001]), and TE removal (RR, 2.05 [ P < 0.001]). These elevated risks persisted at 60 and 90 days after surgery.

Conclusion: Patients who used antibiotics within 30 days before TE-based breast reconstruction had an increased risk of SSIs.

Background: Total ear reconstruction using an autogenous costal cartilage framework within a mastoid skin pocket becomes challenging when suboptimal mastoid skin prevents complete framework embedding.

Methods: Twelve patients with suboptimal mastoid skin underwent a silicone-induced vascularized capsule technique. Eight patients had congenital dystopic lobule-remnant microtia or anotia, accompanied by a severely low hairline, hemifacial microsomia, or both. Three patients had lobule-remnant congenital microtia requiring revision, and 1 patient had posttraumatic microtia. In 7 cases, hair-bearing mastoid skin was treated preoperatively with laser depilation. During the first stage, silicone blocks were placed in the recessed area of the cartilage framework-either the concha (11 patients) or scapha (1 patient)-to promote formation of a vascularized capsule between the silicone and bare cartilage, enhancing skin-to-framework contact. The second stage involved framework elevation to achieve ear projection. In the third stage, silicone blocks were removed, and skin grafts were applied. Two patients were excluded because of incomplete final-stage surgery.

Results: Nine patients developed well-vascularized capsules, enabling full-thickness skin grafting, without tissue loss. One had partial capsule loss from silicone exposure through a scar, but the remaining capsule supported successful grafting. During the 10-month to 4-year follow-up, grafted skin remained stable, with well-preserved contours. The capsule provided additional coverage of 227 mm 2 to 841 mm 2 (mean, 553 mm 2 ). All patients reported high satisfaction.

Conclusion: This technique offers a reliable option for total ear reconstruction in patients with suboptimal mastoid skin, allowing tension-free coverage and stable long-term outcomes.

Background: The authors present a novel microsurgical model to investigate ischemia-reperfusion (I/R) injury in composite tissue (muscle/skin) using a musculocutaneous flap. I/R was induced in a rodent biceps femoris musculocutaneous flap through collateral ligation and arteriovenous clamping. The authors hypothesized that I/R flaps would show greater tissue damage compared with sham.

Methods: Male rats were randomized into I/R ( n = 10) and sham ( n = 9) groups. The I/R group underwent flap elevation, collateral ligation, 3 hours of arteriovenous clamping, followed by reperfusion. The sham group had flap elevation only. Perfusion was monitored using laser-speckle imaging, and flap discoloration was assessed with blinded skin ischemia necrosis scores. Serum and the composite tissue (skin/muscle) were analyzed for injury on postoperative days (PODs) 1 or 3.

Results: Clamping reduced perfusion ( P = 0.00), whereas unclamping increased perfusion ( P <0.00). Over time, flaps exposed to I/R were more ischemic (estimate, 0.39; P = 0.02). At POD1, the injury group had higher serum creatine kinase ( P = 0.04) and potassium ( P = 0.00) than the sham group. The injury group had more muscle apoptosis (34.7% versus 5.2%; P = 0.03), myonecrosis (30.3% versus 14.1%; P = 0.04), and inflammation (13.7% versus 4.9%; P = 0.02) than the sham group; myonecrosis and inflammation persisted into POD3. Skin apoptosis and inflammation were similar.

Conclusions: This model reliably reproduces I/R injury with a 3-hour ischemic period followed by early reperfusion. Animals subjected to the authors' technique showed greater tissue damage than the sham group, with muscle being more vulnerable than skin. Serum showed peak muscle injury at 24 hours, and histologic analysis showed myonecrosis and inflammation through 72 hours. This suggests that less than 24 hours' reperfusion (eg, critical window) may serve as the optimal time for possible intervention.

Clinical relevance statement: I/R injury is a complex phenomenon affecting vascular composite tissues. The mitochondrial superoxide dismutase may be more specific for I/R injury. There may be a critical window within which to mitigate injury (<24 hours after reperfusion). The authors' model helps investigate muscle/skin I/R injury.

Background: The 2-stage Nagata technique is one of the most prevalent methods for auricular reconstruction. Nevertheless, in the second stage, the use of a temporoparietal fascial flap usually requires an additional incision, and the procurement of donor skin from the groin or chest area can result in extra scarring, which may reduce patients' satisfaction with the surgical outcomes.

Methods: The authors propose a refined method using a retroauricular fascia flap combined with a split-thickness skin graft for postauricular coverage, which can avoid additional scarring in the temporoparietal and donor skin area. From April of 2019 to January of 2024, auricular reconstructions on 337 ears across 324 patients were performed using this novel technique. The classification of microtia, duration of surgery, and postoperative complications were recorded. The authors finally evaluated the scar condition and patient satisfaction with surgery outcomes in the 1- to 2-year postoperative period.

Results: In the authors' study, 154 patients were diagnosed with lobule-type microtia, 53 patients were diagnosed with small concha-type microtia, 62 patients were diagnosed with concha-type microtia, and 55 patients were diagnosed patients with anotia. The average duration of the second-stage surgery was 2.8 hours. Patients who underwent this modified technique exhibited no noticeable long-term postoperative scarring and no instances of flap necrosis, framework deformation, cartilage exposure, infection, or mismatched skin color following the procedure. Furthermore, 94% of the patients reported satisfaction with the surgical outcomes.

Conclusion: The use of continuous split-thickness skin grafts, combined with a retroauricular fascial flap, offers a safe, effective, and aesthetically pleasing solution for second-stage auricular projection.

Background: Over the past 16 years, novel approaches to breast cancer surgical care have emerged. This study aimed to provide a contemporary surgical trend analysis for patients with breast cancer and reports trends across all aspects of breast reconstruction, including oncoplastic surgery (OPS).

Methods: A retrospective cohort analysis was conducted using American College of Surgeons National Surgical Quality Improvement Program data from 2008 to 2023. Patients were categorized into surgical groups for partial mastectomy, mastectomy without reconstruction, mastectomy with autologous reconstruction (M+AR), mastectomy with implant reconstruction (M+IR), and OPS. A subgroup analysis was conducted to elaborate further within each reconstructive surgical group.

Results: The primary cohort consisted of 360,731 patients; of those, 119,096 had reconstructive surgery. Annual surgical trends increased for partial mastectomy by 129% and OPS by 408%, and decreased for the mastectomy without reconstruction group by 38% and M+AR by 20% (all P < 0.01). M+IR had no significant trend shift ( P = 0.30). In the reconstructive subgroup analysis, most mastectomy procedures decreased (M+IR by 11%, mastectomy with latissimus dorsi flap by 65%, and mastectomy with transverse rectus abdominis myocutaneous flap by 95%), but mastectomy with free flap increased by 212%. The OPS groups had the most significant increase across all subcategories: level 1 OPS by 587%, level 2 OPS by 194%, and OPS volume replacement by 151% (all P < 0.01).

Conclusions: This study provides a comprehensive analysis of demographic profiles and surgical trends across common breast interventions and reconstructive surgical procedures. These findings suggest that the shift toward OPS and advanced reconstructive techniques is becoming more prevalent and mastectomy without reconstruction is decreasing.

Background: Conservative management with antibiotic therapy may enable implant salvage following infection after device-based breast reconstruction. No existing studies describe the likelihood of implant salvage with respect to the plane of reconstruction in a large patient cohort.

Methods: Patients who underwent device-based breast reconstruction and experienced postoperative infections from January of 2013 to August of 2023 were reviewed retrospectively. Device salvage, the main outcome of interest, was characterized as resolution of infection from management without explantation. Multivariable logistic regression was used to quantify predictors of salvage versus explantation ( P < 0.05).

Results: A total of 2019 breasts in 1206 patients were analyzed. Planes of placement included total submuscular (73.9%), subpectoral with acellular dermal matrix (ADM) (14.0%), prepectoral with ADM (10.5%), and prepectoral without ADM (1.6%). Postoperative infection occurred in 86 breasts (4.3%). The infection rate was highest in subpectoral procedures (8.9%), followed by prepectoral with ADM (8.0%), prepectoral without ADM (6.3%), and total submuscular placement (2.8%). Prepectoral with ADM (OR, 2.79; 95% CI, 1.46 to 5.33; P = 0.0019) and subpectoral (OR, 3.67; 95% CI, 2.15 to 6.24; P < 0.001) placement predicted higher likelihood of infection compared with total submuscular placement, but neither plane predicted significantly different odds of salvage after infection ( P > 0.05).

Conclusions: Management of infection in device-based reconstruction without explantation is a reasonable treatment option with resolution of infection in 36% of cases. Although total submuscular placement confers protection against postoperative infection compared with other planes of placement, it does not add benefit for subsequent success of device salvage.