Plastic and reconstructive surgery最新文献

Summary: Informed consent is the principal tool that bridges the gap between clinical practice and our society's ethical ideals. The intricacies of informed consent, however, are frequently misunderstood, and its effective implementation can be challenging in practice. The continuous stream of innovations, wide array of procedures, and other characteristics inherent to the practice of plastic surgery compound the challenges of implementing informed consent. Unfortunately, there remains a dearth of literature to provide a comprehensive overview of informed consent as it relates to plastic surgery. In this article, the authors highlight the history, legal components, and challenges of informed consent within plastic surgery and offer recommendations on how to approach them. A deeper understanding of informed consent helps enhance patient care, mitigates unnecessary malpractice risk, and leads to better physician-patient relationships.

Background: Postmastectomy autologous breast reconstruction can be immediate or delayed. The safety of performing immediate breast reconstruction (IBR) and the impact of radiation on the newly reconstructed breast is not yet validated.

Methods: A PubMed, Embase, and Google scholar search was conducted from inception to September 17, 2023. The authors included comparative studies that assessed complications or aesthetic outcomes of IBR versus delayed breast reconstruction (DBR) in the setting of postmastectomy radiotherapy (PMRT).

Results: The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy, whereas 699 had DBR. Mean follow-up time and age for both groups were comparable ( P > 0.1). None of the complications-revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing-were significantly different across groups ( P > 0.1). IBR was found to have a higher risk of flap fibrosis (OR, 28.18; 95% CI, 5.15 to 154.12; P = 0.0001; I2 = 44%) and skin flap necrosis (OR, 6.12; 95% CI, 2.71 to 13.82; P < 0.0001; I2 = 27%) but a lower risk of partial flap failure (OR, 0.18; 95% CI, 0.06 to 0.58; P = 0.004; I2 = 0%) when compared with DBR. Results of fat necrosis should be interpreted with caution. Patient-reported and objective aesthetic outcomes were mostly comparable between groups.

Conclusions: IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires.

Background: The assessment of scar outcomes is important to both patient care and research focused on understanding the results of medical and surgical interventions. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) are validated and simple instruments to assess scars. However, these subjective scales have shortcomings. The VSS fails to capture patient perception and has indeterminate validity and reliability. The POSAS captures patient perception, but the observer scale has been shown to have moderate amounts of interrater variability. Studies highlighting the ability of objective scar assessment tools to produce reliable and reproducible results are needed. In this study, the authors aimed to validate the use of the FibroMeter, ElastiMeter, and SkinColorCatch as objective adjuncts in the assessment of hypertrophic scar and keloid outcomes.

Methods: In this prospective single-center study, scars were assessed using the VSS, the POSAS, and the objective study tools (FibroMeter, ElastiMeter, and SkinColorCatch). Correlations between the different methods of scar assessment were measured.

Results: The FibroMeter and SkinColorCatch showed significant correlations with the VSS total and the observer POSAS total. The ElastiMeter showed significant correlations with both the patient and observer POSAS totals. Unexpected correlations between ElastiMeter measurements and the vascularity or pigmentation of scars indicate that scoring of these categories may be influenced by how severe the scar looks to the observer subjectively, underscoring the need for reliable objective scar assessment tools.

Conclusion: The results highlight the ability of the FibroMeter, ElastiMeter, and SkinColorCatch to assess scars, and demonstrate their potential in serving as important adjuncts to previously validated scar assessment scales.

Purpose: The authors examined the effects of race and ethnicity on the likelihood of experiencing delays to surgery, postoperative surgical complications, and prolonged hospital length of stay (LOS) after primary cleft lip repair.

Methods: Patients who underwent cleft lip repair were identified in the 2006 through 2012 Kids' Inpatient Database. Primary outcomes were defined as treatment after 6 months of age, any surgical complication, LOS greater than 1 day, and total hospital charges. Multivariable analyses were performed to adjust for sociodemographic and clinical characteristics that might account for differences in outcomes.

Results: There were 5,927 eligible patients with cleft lip: 3,724 White, 1,316 Hispanic, 279 Black, 277 Asian or Pacific Islander, and 331 other (including American Indian or Alaska Native, multiple races, or races/ethnicities not specified within the dataset). Across all outcomes, there were significant unadjusted differences ( P < 0.001) by race and ethnicity, with White children having the lowest odds of delayed surgery, complications, and prolonged LOS, and the lowest charges. Multivariable analyses suggested that differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type, and location. Even after adjusting for covariates, significantly increased odds of delayed surgery and higher charges remained for Hispanic and Asian or Pacific Islander patients.

Conclusion: There are significant differences in the odds of delays, complications, prolonged hospital stays, and total charges among patients with cleft lip of different races or ethnicities. Advocacy efforts to ameliorate disparity in early infant health may subsequently improve equity in cleft outcomes.

Clinical question/level of evidence: Risk, II.

Background: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction.

Methods: The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs).

Results: The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence.

Conclusions: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence.

Clinical question/level of evidence: Therapeutic, IV.

Background: Gender-affirming feminizing hormone therapy induces body fat redistribution. However, the amount and timing of facial fat changes in response to feminizing hormone therapy are unknown, despite being relevant to counseling and surgical planning for facial gender-affirming surgery. The authors assessed the influence of feminizing hormone therapy duration on malar and temporal fat volume.

Methods: Malar and temporal fat volumes were compared using computed tomography in transfeminine patients (age, 20 to 29 years; body mass index, 18.5 to 24.9) treated with feminizing hormone therapy for less than 2 years versus 2 years or longer. Patients with previous surgical or nonsurgical facial soft-tissue interventions were excluded. Multivariable linear regressions evaluated the contribution of hormone therapy duration to malar and temporal fat volumes.

Results: A total of 45 patients were included, 30 (66.7%) treated with feminizing hormone therapy for 2 years or longer and 15 (33.3%) treated for less than 2 years (median [interquartile range], 44.5 [33.5 to 65.6] versus 15.0 [11.0 to 18.0] months; P < 0.001). Patients treated with hormone therapy for 2 years or longer demonstrated a 1.6-fold greater malar fat volume (5.5 [4.2 to 6.3] versus 3.4 [2.3 to 4.2] cm 3 ; P < 0.001) and 1.4-fold greater temporal fat volume (2.8 [2.4 to 3.6] cm 3 versus 2.0 [1.7 to 2.4] cm 3 ; P = 0.01) compared with those treated for less than 2 years. When accounting for other contributory variables, such as body mass index, skull size, and total soft-tissue depth, in multivariable linear regression models, hormone therapy duration of 2 years or longer independently predicted higher malar (β = 0.51, P < 0.001) and temporal (β = 0.32, P = 0.02) fat volumes.

Conclusion: Feminizing hormone therapy increases malar and temporal fat volumes by approximately 2 cm 3 and 0.8 cm 3 for each area, respectively, after 2 years of treatment.

Clinical question/level of evidence: Therapeutic, III.

Summary: As the most prominent feature of the lower face, the chin is crucial to human facial morphology, and plays a large role in contributing to facial attractiveness and harmony. Although an increasing number of genioplasty procedures are being introduced for chin augmentation, chin reduction procedures are rarely performed. Because of the inevitable cervicomental angle widening and relaxation of the floor-of-mouth muscles caused by chin shortening and the elevation of the lower edge of the mandible, chin reduction remains a challenging procedure. The authors' novel drawer-genioplasty approach involves a flexible chin-reducing procedure using subapical and mandibular contouring ostectomy. This technique can effectively shorten various types of long chin for improved facial proportions and maximize floor-of-mouth muscle protection during surgery, thereby avoiding postoperative submental sagging. Several measures, including the ratio between the lower (subnasale to menton distance) and middle facial heights (glabella to subnasale distance) (R1), the ratio between the anterior midline bone heights of the mandible (stomion to menton distance) and maxilla (subnasale to stomion distance) (R2), and the cervicomental angle, were used to evaluate the outcome of the procedure. Comparing the preoperative and postoperative measures revealed that there was a significant decrease in both R1 (1.25 ± 0.15 versus 1.09 ± 0.12) and R2 (1.94 ± 0.24 versus 1.58 ± 0.11). Although cervicomental angle increased from 107.3 ± 8.2 degrees preoperatively to 112.4 ± 7.0 degrees postoperatively, this value was still within the normal range. In addition to providing effective and significant aesthetic improvements, drawer genioplasty is safe and involves no complications.

Clinical question/level of evidence: Therapeutic, IV.

Background: Breast cancer has surpassed lung cancer to become the most frequently diagnosed cancer in women. There has been a dramatic increase in the use of breast reconstruction after mastectomy. However, struggle in making decisions regarding breast reconstruction has existed. Thus, a study of decision aids (DAs) needs to be conducted, and further studies are needed to promote better DAs. This review discusses how DAs can be used to help women make decisions about breast reconstruction after mastectomy. In addition, the review was the first to compare different DA formats to determine which one is most effective.

Methods: The authors searched for relevant studies published before October of 2022 in PubMed and Embase using the medical subject headings "breast reconstruction" and "decision aid." Demographic data and decision, outcomes, and instruments used for assessment were also collected. Risk of bias was measured by the Cochrane Risk of Bias 2 tool.

Results: A network meta-analysis of 14 RCTs with a total of 1401 patients were included. A total of 90.9% participants presented usable results for evaluation of decisional conflict, and web-based DA (-0.3; 95% CI, -0.56 to -0.05) showed significant improvement; 50.3% of participants provided results of decisional regret, and no subgroups showed significant reduction; 60.3% of participants contributed to results for knowledge, and web-based DA (0.61; 95% CI, 0.01 to 1.21) showed the most positive effect. A total of 44.5% of participants were included for evaluation of satisfaction, and web-based DA (0.44; 95% CI, 0.15 to 0.72) revealed significant increase.

Conclusion: The review concluded that web-based DAs are the favorable format of DA.

Clinical question/level of evidence: Therapeutic, II.

Background: The aim of this systematic literature review was to describe current indications and interventions for revisions after trapeziometacarpal joint (TMJ) resection arthroplasty.

Methods: The literature search was conducted by an experienced librarian in the MEDLINE, Embase, Cochrane Library, Web of Science, and Scopus databases. The authors included all articles that investigated any TMJ arthroplasty procedure in which the trapezium was completely resected and if any subsequent revision procedure including joint-related and soft-tissue operations was mentioned. Two independent reviewers selected the articles and were involved in data extraction.

Results: Sixty-two articles reporting on 5284 operated thumbs and 434 revision operations were included. Twenty-four indications for revision and 31 revision techniques were extracted. Most revisions were performed because of subsidence/impingement of the first metacarpal bone ( n = 194 thumbs) followed by unspecified pain ( n = 53), metacarpophalangeal joint problems ( n = 28), and scaphotrapezoidal osteoarthritis ( n = 17). Eleven treatment strategies were found for subsidence/impingement of the first metacarpal, the most frequent being revision of the existing interposition using autologous tendon ( n = 46) and soft-tissue interposition with distraction pinning ( n = 28).

Conclusions: There are a wide variety of indications and even more surgical techniques described in the literature to treat persisting or recurrent pain after TMJ resection arthroplasty. Currently, there is no uniform treatment guideline available on how to diagnose and treat such cases. Therefore, the results of this literature review will form the basis for a Delphi study aiming to develop recommendations for the diagnosis and treatment of persistent/recurrent pain after TMJ resection arthroplasty.