Plastic and reconstructive surgery最新文献

Background: Residual limb pain (RLP) and phantom pain can arise following amputation and may require additional treatment or surgery. This study aimed to determine the prevalence of neuropathic RLP following limb amputation and identify prognostic factors for the development of neuropathic RLP.

Methods: A cross-sectional study was performed of patients who underwent upper or lower extremity amputation between 1990 and 2021 with a minimum of 12 months' follow-up. The primary outcome was the prevalence of neuropathic RLP, defined as a 0 to 10 numeric rating analog scale pain score in the residual limb of greater than or equal to 4, in combination with a score greater than or equal to 4 on the short-form Douleur Neuropathic 4 questionnaire, validated for discriminating between nociceptive and neuropathic pain. The secondary outcome was quality of life for amputation patients with and without (neuropathic) RLP. A multivariable linear regression model was used to identify prognostic factors for neuropathic RLP development.

Results: A total of 121 patients were included: 87 with lower extremity amputations, 29 with upper extremity amputations, and 5 with both. Neuropathic RLP was experienced by 21.5%, whereas 10.7% reported nonneuropathic RLP. Smoking status and complex regional pain syndrome as indications for limb amputation were associated with more severe neuropathic pain symptoms. Patients experiencing neuropathic RLP reported a significantly lower quality of life compared with patients without neuropathic RLP.

Conclusions: This study demonstrates that neuropathic RLP is common after limb amputation and impacts daily functioning. The absence of numerous manageable prognostic factors associated with neuropathic pain development emphasizes the importance of the consideration of prophylactic interventions at the time of amputation.

Clinical question/level of evidence: Risk, III.

Background: Although breast explantation combined with mastopexy is an increasingly common procedure, it does present certain technical difficulties. The authors present a technique of explantation mastopexy with the use of an extended lateral pedicle for autoaugmentation.

Methods: A consecutive series of 40 cases was reviewed retrospectively, with a patient-reported outcome questionnaire and photography at 3 and 12 months.

Results: The mean patient age was 57 years (range, 40 to 70 years), and the mean duration of implantation was 20.4 years (range, 7 to 42 years). Twelve women had undergone previous mastopexy (30%). Minor wound complications requiring simple dressings were seen in 7 patients (17.5%). Major infected wound problems occurred in 1 patient, who was a smoker and had other comorbidities. All except 1 patient reported being satisfied or very satisfied with the outcome, with a mean patient-reported satisfaction score of 4.9 of 5. When the photographs were independently assessed by a cosmetic practitioner, all patients were rated as average, good, or very good, with a mean score of 4.1 of 5.

Conclusions: The procedure is associated with low risk of postoperative complications, good cosmetic outcomes, and a high degree of patient satisfaction. The authors believe this technique provides a logical, reproducible method for combined explantation and mastopexy.

Clinical question/level of evidence: Therapeutic, IV.

Background: Cell-assisted lipotransfer (CAL) and platelet-rich plasma (PRP)-assisted lipotransfer have been used to overcome the low survival rate of conventional lipotransfer. However, there is still insufficient evidence to determine which technique is the best strategy for autologous fat grafting in breast cosmetic and reconstructive surgery. The present study aimed to compare the efficacy of traditional fat transplantation, CAL, and PRP-assisted lipotransfer.

Methods: A systematic search was conducted in several databases, including PubMed, Web of Science, Cochrane, ClinicalTrials.gov, and Embase, concluding on January 21, 2024, to identify studies that met the inclusion criteria. Twelve studies were included after a rigorous selection process based on predefined criteria. Statistical analyses were conducted using R version 4.0.5 software with the netmeta and dmetar packages, utilizing a frequentist approach with a random-effects model. A network meta-analysis was performed to compare different fat graft procedures with regard to fat survival rate and complication events.

Results: CAL and PRP-assisted lipotransfer were better than traditional fat grafting in terms of fat survival rate. In addition, there was no significant difference in the incidence of postoperative complications among the CAL, PRP, and traditional groups.

Conclusions: Given the results of network meta-analysis, it appears that both CAL and PRP-assisted lipotransfer have a higher fat survival rate for autologous fat grafting in breast augmentation and reconstruction. However, the transplantation strategy still needs to be analyzed based on actual conditions in clinical applications.

Background: With an increasing need for thin flaps, the use of superthin anterolateral thigh (ALT) flaps, raised above the supra-superficial fascia, has drawn great attention. Controversy remains regarding whether such thin-flap elevation could affect postoperative outcomes, encompassing perfusion-related complications (PRCs) and donor-site morbidity. This study aimed to evaluate the outcomes of superthin ALT flap-based reconstruction compared with those of suprafascially elevated flaps.

Methods: Patients who underwent free ALT flap-based reconstruction between March of 2017 and June of 2023 were reviewed and categorized into 2 groups based on flap elevation plane: superthin or suprafascial. Development of PRC and donor-site morbidity, including paresthesia, was compared. Independent associations of the elevation plane with complication profiles were evaluated. Further analyses were conducted using propensity score matching.

Results: In total, 208 cases were analyzed: 80 superthin and 128 suprafascial ALT flaps. Nineteen cases (9.1%) experienced PRC, including 4 total and 14 partial necrosis. The incidence of overall and each type of PRC did not differ based on flap elevation plane even after adjusting for other variables. The superthin group exhibited significantly lower donor-site complications compared with the others, which was upheld in multivariable analyses. Elevating the flaps in a superthin fashion allowed for a higher rate of preservation of the lateral femoral cutaneous nerve, resulting in a significantly lower rate of postoperative paresthesia. Similar associations were observed in the propensity score matching analysis.

Conclusion: Superthin ALT flap elevation does not appear to increase PRC risk and reduces donor-site complications, compared with suprafascial elevation.

Clinical question/level of evidence: Therapeutic, IV.

Summary: Indocyanine green angiography (ICGA) is a useful tool for the visual assessment of superficial blood flow. The authors used ICGA to visualize perforator branches and linking vessels to provide a road map for flap design of an expanded flap. Twenty-eight expansions were planned to use the back-cut technique in 26 patients. ICGA was used to visualize the perforator branching pattern with the linking vessels and the venous network in the expanded flap before expander explantation. The appropriate perforator was selected, and the flap was designed following the axiality of its branch linked by true anastomoses. The vein running closely was chosen as the axial vein. The back cut was designed to avoid transection of the axial artery and vein. Patient characteristics, defect characteristics, and reconstructive outcomes were assessed. ICGA clearly visualized the perforator branches and the linking vessels in the expanded flap at 4the head and neck, trunk, and extremity. The back-cut flap containing the axial artery and vein was raised successfully in 27 expansions. The arterial perforator and superficial vein separated greatly and resulted in design modification from back-cut to advancement flap in one expansion. All expanded flaps met the reconstructive needs and exhibited complete survival. ICGA allowed the visualization of the preoperative topography of the vascular network in the expanded flap and helped surgeons locate the vascular axis and perform an appropriate back-cut design for efficient and safe flap transfer.

Clinical question/level of evidence: Therapeutic, IV.

Background: Previously published research describes short-term outcomes after proximal interphalangeal (PIP) joint arthroplasty; however, long-term outcomes are scarce. Therefore, the authors evaluated patient-reported outcomes and complications after a follow-up of at least 5 years following PIP joint arthroplasty.

Methods: The authors used prospectively gathered data from patients undergoing PIP joint arthroplasty with silicone or surface replacement implants. Time points included preoperatively, 1 year postoperatively, and at least 5 years postoperatively. The authors were able to include 74 patients. Primarily, the authors focused on patient satisfaction with the treatment outcome, measured using a validated 5-point Likert scale. Secondary outcomes included the questions of whether patients would undergo the same surgery again, the assessment of factors associated with satisfaction or dissatisfaction, the Michigan Hand Outcomes Questionnaire score, and the number of reoperations.

Results: The mean follow-up was 7 ± 1.2 years (range, 5 to 11 years). Patient satisfaction was excellent in 14 patients (19%), good in 17 patients (23%), reasonable in 18 patients (24%), moderate in 10 patients (14%), and poor in 15 patients (20%). Seventy-three percent of patients ( n = 54) would undergo the same procedure again. The authors found no factors associated with satisfaction or dissatisfaction. All Michigan Hand Outcomes Questionnaire scores improved significantly in the first year after surgery and did not deteriorate afterward. Sixteen fingers (16%) required a reoperation, of which 3 (4%) needed a prosthesis replacement.

Conclusions: Patient satisfaction with treatment outcomes 7 years after PIP implant surgery ranges from moderate to good for many patients, with a notable proportion expressing dissatisfaction. Patient-reported outcomes improve primarily within the first year and remain stable at 5 years or more.

Clinical question/level of evidence: Therapeutic, IV.

Summary: Improvements in the management of pediatric sarcoma, including imaging, neo- and adjuvant therapy, and surgical technique, have enhanced long-term survival. Pediatric patients diagnosed with a femoral osteosarcoma undergoing oncologic resection who are ineligible for limb-preservation reconstruction or rotationplasty are offered an above-knee amputation (AKA). Limb amputation in the skeletally immature patient poses particular problems specific to endosteal bone overgrowth and spiking. Approximately half of these patients undergo revision of their amputation site. Furthermore, a high AKA often requires a hip-based prosthesis, which can be uncomfortable, leading to poorer outcomes and higher energy expenditures. The authors have completed 4 "spare parts" microvascular free tibial transfers for pediatric patients diagnosed with femoral osteosarcoma who were treated with an AKA. Two of these patients are ambulatory with their prosthesis and have not required long-term revision of their amputation site. One patient demonstrated radiographic evidence of bony union 4 months postoperatively, but subsequently died of chemotherapy-resistant metastases. The fourth patient is in the process of prosthetic fitting and rehabilitation. This is a novel technique, and the authors present the first series describing both proximal and distal free microvascular tibial bone transfers as a reconstructive option for pediatric patients with femoral osteosarcomas. This reliable flap, which has possible variations in vascular anatomy, offers multiple benefits, including prevention of bony spiking, AKA stump augmentation, and facilitation of appropriate prosthetic fitting, improving functional outcomes and leading to decreased energy expenditure. The soft-tissue coverage must be well-planned.

Summary: The single port robotic nipple sparing mastectomy (SPrNSM) was recently introduced. This approach is safe and has led to favorable outcomes in relation to cosmetic result, patient satisfaction, and breast sensation. The typical reconstruction with all robotic nipple sparing mastectomies is implant based; however, this is not always what a patient desires. We present autologous tissue reconstruction with PAP flaps following SPrNSM using the same axillary incision. A retrospective review of all patients treated with a PAP flap for breast reconstruction and SPrNSM at our institution from July 2022 to May 2023 was performed. Six patients underwent SPrNSM with PAP flap breast reconstruction (three delayed immediate and three immediate reconstruction). Three patients underwent subsequent revision with fat grafting. Breast reconstruction following robotic nipple sparing mastectomy has typically been performed with implants. We present a series of patients treated with PAP flaps for autologous reconstruction utilizing the same remote axillary incision as used in SPrNSM.

Background: The upregulation or delay of acute inflammation at any stage limits fat graft survival. Active endogenous inflammation resolution mechanisms and mediators are novel therapeutic tools for inflammation. This study explored the effects of supplementation of omega-3 polyunsaturated fatty acids (PUFAs) deriving specialized proresolving mediators (SPMs) on postoperative inflammation and graft survival in vivo.

Methods: Fish oil (FO) (or saline for the control group) was intragastrically administered in the C57BL/6N mouse fat graft model for a week before and after transplantation. The mice were euthanized at 3, 7, 14, 30, or 90 days posttransplantation. Serum C-reactive protein (CRP) concentration was determined via enzyme-linked immunosorbent assay (ELISA); gene expression levels of inflammatory factors, perilipin-1 and vascular endothelial growth factor (VEGF) in the grafts were analyzed via quantitative real-time PCR (QPCR); hematoxylin and eosin (H&E), masson's trichrome, immunohistochemistry (IHC) and immunofluorescence (IF) staining were performed.

Results: Omega-3 PUFAs reduced the serum CRP concentration. Additionally, in the grafts of FO group, proinflammatory factors expression was reduced while anti-inflammatory factors expression was increased; the CD11b+ IF intensity at Days 14 and 30 was reduced, the F4/80+/CD11b+ ratio at Days 3 and 7 and the CD206+/F4/80+ ratio at Days 7, 14, and 30 were increased, consistent with the results of IHC control staining (CD11b, F4/80 and CD206); the gene expression of VEGF at Day 14 and perilipin-1 at Days 30 and 90 were increased; the perilipin-1+ %area and CD31+ %area at Day 90 were increased; inflammatory cell infiltration and fibrosis were decreased.

Conclusion: Omega-3 PUFAs can enhance inflammation resolution and angiogenesis and promotes fat graft survival in a controlled mouse model.

Summary / unstructured abstract: Emphasis on enhanced recovery after surgery (ERAS) protocols and opioid use reduction have led to a growing interest in alternative pain management strategies. This study describes and evaluates the ultrasound-guided suprazygomatic maxillary (SZM) nerve blocks for patients undergoing functional and cosmetic nasal surgery as an adjunct to postoperative pain management. A retrospective, multicenter analysis was conducted on patients who underwent functional nasal surgery and rhinoplasty and evaluated the impact of SZM blocks on intraoperative anesthetic and opioid use, postoperative pain scores recorded in the PACU, and PACU length. A total of 64 patients met inclusion criteria. Twenty-five patients received a SZM block prior to undergoing the procedure while the remaining patients underwent standard local anesthetic use. SZM blocks significantly reduced the amount of intraoperative pain medication used (p = 0.02), including hydromorphone (p=0.007), when compared to a traditional approach to local anesthetic use. SZM blocks also significantly reduced post-anesthesia PACU stay at one institution (p=0.016). SZM nerve blocks are a simple and effective way to deliver local anesthetic and are associated with decreased intraoperative opioid use and PACU stay.