Plastic and reconstructive surgery最新文献

Introduction: Targeted therapies, including pembrolizumab and CDK4/6 inhibitors, have expanded treatment options for breast cancer subtypes such as triple-negative (TNBC) and hormone receptor-positive/HER2-negative cancers. However, their impact on surgical outcomes in two-stage prepectoral breast reconstruction remains unclear. This study evaluates surgical outcomes in patients receiving pembrolizumab or CDK4/6 inhibitors.

Methods: A retrospective review was conducted of all patients at a single institution who underwent immediate two-stage prepectoral reconstruction at a single center between January 2018 and October 2024 with ≥3 months of follow-up. Exclusion criteria included autologous, delayed, or direct-to-implant reconstructions, and chemotherapy after implant exchange. Variables analyzed included cancer characteristics, treatments, and postoperative complications. Major complications were defined as those requiring readmission or reoperation. Statistical analyses were performed using Fisher's Exact and Wilcoxon Rank Sum tests.

Results: Of 472 patients, 27 received pembrolizumab and 30 received CDK4/6 inhibitors. Pembrolizumab had significantly higher seroma rates during expansion (44.4% vs. 27%, p=0.05). After implant exchange, major complications (26.3% vs. 8%, p=0.02) and reoperation rates (19.1% vs. 3.7%, p=0.01) were significantly higher. Patients receiving CDK4/6 inhibitors did not experience an increased risk of infection; in fact, the observed rate of minor infections was lower (0.0% vs. 12.4%, p=0.04), although no significant differences were seen in other outcomes.

Conclusion: Pembrolizumab is a promising therapy for TNBC, but its association with increased seromas, major complications, and reoperations warrants further investigation. Use of CDK4/6 inhibitors was not associated with an increased risk of infection following tissue expander placement.

Objective: Aim of this study is to evaluate the effectiveness of stromal vascular fraction (SVF) and nano-fat applications on photoaging and skin quality in the facial region, as well as their possible superiority over each other.

Materials and methods: Study was conducted on 20 volunteer patients aged 40-55 who applied to City Hospital Plastic Reconstructive and Aesthetic Surgery outpatient clinic between April-July 2024 with complaints of facial aging and skin complaints in facial area. After initial evaluation, patients were divided into two groups; SVF was injected into the facial region of 10 patients, and nano-fat was injected into facial region of the other 10 patients. Preoperative, postoperative 1st and 3rd month skin evaluations of the patients were made with the visa skin analysis system, and dermis thicknesses were measured with high-frequency ultrasound (HFU). The data obtained prospectively were statistically analyzed.

Results: In the visia skin evaluations of the patients, it was observed that SVF and nano-fat injection reduced wrinkle scores significantly (p<0.05). Also, SVF injection reduced ultraviolet (UV) damage, red area and porphyrin score significantly (p<0.05). No significant dermis change was detected in the dermis thickness measurement performed with HFU preoperatively and postoperatively.

Conclusion: It was observed that SVF and nano-fat injections were effective on wrinkles and both applications were valuable in anti-aging treatments. SVF application was effective in reducing UV damage, vascular pathologies and inflammation. So, it can be said that SVF applications are useful treatment methods in reducing photoaging and improving skin quality.

The healthcare sector has become a prime target for private equity (PE) investors, with major firms investing in service platforms, medical devices, pharmaceuticals, and digital health. PE investors acquire companies, restructure them, and then resell the entities, typically within a three to seven-year timeline. From 2010 to 2020, PE investments in the healthcare sector increased by 166%, with $750 billion invested in the U.S. alone, and $115 billion invested globally in 2024. PE firms have invested increasing amounts in the plastic surgery specialty, with acquisition volume rising 4,300% and capital investments increasing 7,630% between 2000 and 2023. These trends are driven by market fragmentation, growth potential, and favorable financial characteristics, including high profit margins and recurring revenue. Financial sponsors have targeted practices with roll-up strategies and platform consolidations to achieve economies of scale. Policy variables, including Medicare reimbursement disparities and regulatory constraints on physician-owned hospitals, further incentivize consolidation. In response, multiple states, including Massachusetts and Indiana, have enacted transparency laws, and federal agencies have scrutinized the impact of PE on competition and care quality. In this manuscript, we encourage plastic surgeons to advocate for physician-friendly policies, pursue collaborative ownership models with PE sponsors, and engage in research on PE's impacts on care. As PE entities expand their ownership stake in plastic surgery and the broader healthcare sector, physicians must take a proactive role in the management, ownership, and policy issues that will govern such arrangements to safeguard care quality and physician autonomy.

Introduction: Acellular dermal matrix (ADM) is frequently used in two-stage prepectoral breast reconstruction; however, concerns persist regarding increased infection rates with its use and overall benefits. This randomized controlled trial evaluated whether ADM in prepectoral reconstruction is noninferior to the alternative of no ADM with regard to major postoperative complications.

Methods: In this single-center, cluster-randomized noninferiority trial, 368 patients (623 breasts) undergoing two-stage prepectoral reconstruction were assigned to ADM or no ADM groups. The primary endpoint was the proportion of breasts with at least one major complication (infection, reoperation, or explantation) within 90 days. Noninferiority was defined as the upper bound of the one-sided 95% confidence interval (CI) for the difference in complication rates (with ADM minus no ADM) being less than the pre-specified margin of 7%. Secondary outcomes included minor complications, BREAST-Q scores, and pain.

Results: Major complications were similar between groups (ADM: 13.2% vs. no ADM: 13.1%; one-sided 95% CI upper bound below 7%), confirming noninferiority. Minor complications, including seroma (ADM: 20%, no ADM: 27.4%; p=0.056) showed no significant difference. BREAST-Q scores were comparable at 30 (ADM: 60, no ADM: 55; p=0.2) and 90 days (76 in both groups; p=0.3). Postoperative pain was similar between groups.

Conclusion: Two-stage prepectoral breast reconstruction with ADM was noninferior to reconstruction without ADM regarding major 90-day postoperative complications, with comparable minor complications, patient-reported outcomes, and pain. These findings support the routine use of ADM as a safe option. Long-term follow-up comparing relevant clinical outcomes is needed to clarify the benefits of ADM.Trial Registration: Clinicaltrials.gov NCT05316324.

Background: Adhesion formation following flexor tendon repair remains a significant clinical challenge, often necessitating reoperation and leading to suboptimal outcomes. Current adhesion barrier technologies have limited efficacy and usability.

Methods: A flowable extracellular matrix (ECM) hydrogel and ECM mesh were evaluated in a preclinical rabbit model of flexor tendon repair. Range of motion (ROM), adhesion scoring, and rupture strength were measured. Safety and overapplication effects were assessed in cadaveric tendon models. Histologic analysis evaluated inflammation.

Results: The ECM hydrogel and mesh reduced adhesions and improved ROM compared to saline controls. ROM in treated tendons ranged from 70.4°±17.7° (3:1 Gel) to 69.8°±8.3° (1:1 Gel), significantly higher than controls (50.7°±17.7°; p<0.05). Adhesion scores improved across treated groups, with 1:1 Gel achieving the best results (5.2±1.8 vs. control 8.0±1.5; p<0.05). Histology suggested reduced sustained inflammation in treated groups. No impact on rupture strength was observed, confirming mechanical safety.

Conclusions: Flowable ECM hydrogel and ECM mesh significantly reduce adhesions and preserve tendon mechanics after flexor tendon repair. The hydrogel's flowable form offers superior ease of application, addressing unmet clinical needs.

Background: Breast Implant Illness (BII) refers to a wide range of symptoms reported by women with breast implants. Its underlying etiopathology remains unclear, and it is not officially recognized as a medical diagnosis, resulting in divergent perspectives among clinicians and patients. This systematic review provides a comprehensive overview of symptoms associated with BII and highlights the influence of methodology on the reported spectrum.

Methods material: Multiple electronic databases were searched using the term "Breast Implant Illness". Of 871 identified studies, 23 were included in the qualitative analysis. From these, 19 were used to conduct a quantitative trend analysis of the "Top 20 BII-symptoms surveyed" and the "Top 20 BII-symptoms reported", along with their distribution across organ systems. In addition, the specific tools and strategies used for symptom collection were analyzed.

Results: A total of 98 symptoms were identified. "Fatigue" was most frequently reported, followed by "arthralgia/joint pain" and "myalgia/muscle pain". Symptoms affecting the nervous system and sensory organs predominated. Substantial methodological variability was observed, with only four studies using standardized questionnaires.

Conclusion: The extensive range of symptoms reflects not only clinical heterogeneity but also methodological inconsistencies. The frequent presence of secondary diagnoses further complicates attribution to implants. A way forward includes the use of standardized, validated questionnaires and instruments addressing psychological domains, administered at predefined time points. Achieving international consensus on such tools is crucial to minimize bias, improve comparability, and enable prospective studies to clarify causal links and support the recognition of BII as a distinct clinical entity.

Background: Despite increasing emphasis on early postoperative recovery, lower extremity microsurgical reconstruction has been overlooked, likely due to concerns of high complication rates and the challenges of a gravity-dependent, weight-bearing region. This study evaluated the feasibility and outcomes of stepwise ERAS protocol implementation in this setting.

Methods: A retrospective review was conducted of consecutive lower extremity free flap reconstructions from January 2020 to February 2024, during which postoperative management evolved stepwise toward early recovery. Patients were categorized into three cohorts-pre-ERAS, transition, and ERAS. In the ERAS cohort, oral intake resumed on POD 1 morning, wheelchair-assisted ambulation began that afternoon, and discharge was targeted for POD 5. Postoperative course and complication rates were compared, and the independent association of ERAS implementation was assessed.

Results: In total, 240 flaps in 224 patients were included: 66 pre-ERAS, 123 transition, and 51 ERAS. Following full protocol adoption, median nil per os (NPO) duration decreased from 24.9 to 12.7 hours, bed rest from 4.0 to 1.0 day, and length of stay (LOS) from 11.5 to 7.0 days. Flap- and donor-site complication rates also declined significantly over time. On multivariable analysis, ERAS implementation was associated with shorter NPO duration and reduced bed rest, without an increase in flap-related complications. The reduction in LOS associated with ERAS implementation was particularly pronounced in patients with ASA class <3 or those undergoing oncologic reconstruction.

Conclusion: Stepwise adoption of an ERAS-based protocol in microsurgical lower extremity reconstruction might be feasible and effective, promoting early recovery without increasing complication risk.

Background: The burden of congenital limb and musculoskeletal (CLM) anomalies disproportionately affects low- and middle-income countries (LMICs). The objective of this cross-sectional study was to examine the relationship of the global burden of these conditions with other developmental indicators, including financial, geographic, technological, and healthcare workforce metrics.

Methods: Prevalence and disability-adjusted life year (DALY) rates of pediatric CLM anomalies were extracted from the 2021 Global Burden of Disease database for each country. Multiple economic, geographic, and workforce variables were obtained from the World Bank, International Road Federation, International Telecommunications Union, and World Health Organization. Multivariable analysis with appropriate model selection was used to determine the association of these variables with log-transformed DALYs (logDALYs).

Results: After multiple imputation of missing variables, model selection identified three variables: 1) Risk of catastrophic expenditure for surgical care, 2) internet access, and 3) number of doctors for use in regression analysis in addition to prevalence. On multivariable regression, increased prevalence, lower rates of internet access, and fewer doctors were independently associated with logDALYs.

Conclusions: Patients with CLM conditions require highly specialized, long-term access to surgical, medical, and rehabilitative services. Bolstering physician workforce, increasing services to patients in rural areas, and expanding internet infrastructure in LMICs will decrease barriers to care for patients with CLM conditions.

Background: Burn wound management is guided by the depth of dermal tissue damage. Standard practice for this depth assessment is daily visual evaluation of the wound by an experienced burn surgeon, which is inherently subjective and at times inaccurate. Perioperative fluorescence imaging with indocyanine green (ICG) has emerged as a potential tool to objectively evaluate burn depth. The current study aims to explore the relationship between ICG angiography (ICGA), Second-window ICG (SWIG), and burn depth, with the goal of understanding how this technology could guide the prognosis and treatment of human burn wounds.

Methods: Patients (n = 14) with indeterminate depth or deep partial thickness burns received an infusion of ICG on post-burn day 2-3 or the day before surgery. Imaging was performed immediately after injection for angiography as well as the following day for SWIG. A full-thickness tissue biopsy was obtained for histologic evaluation. In vitro primary human fibroblasts and keratinocytes were cultured, subjected to heat injury (65 deg C for 2.5 or 5 minutes), and incubated with ICG. Flow cytometry was used to classify the cells as live, apoptotic, or necrotic based and to quantify ICG uptake.

Results: ICGA perfusion parameters are increased in burn wounds that did not require grafting and ICGA egress slope correlates to SWIG fluorescence intensity. Furthermore, SWIG microscopic fluorescence intensity correlates to histologic burn depth and colocalizes in necrotic region of burn injury, however there is high interpatient variability between SWIG fluorescence intensity and histologic burn depth, predicted healing potential, and graft status. Flow cytometric analysis of in vitro skin cells shows that preferential ICG binding to necrotic cells contributes to SWIG signal in a burn, with binding influenced by cell type and injury severity.

Conclusions: Overall, this study suggests that fluorescence imaging has the potential to aid in the assessment of healing potential, although current challenges related to imaging variability, interpretation, and clinical integration must be addressed to optimize its utility in burn management.Clinical trials number: NCT05593523.