Plastic and reconstructive surgery最新文献

Summary: This novel hybrid single-double-single barrel (1-2-1) design for fibula free flap reconstruction addresses the unique challenges presented by Brown Class III mandibular defects, which involve long-span defects at both bodies of the mandible and the chin. The importance of this design lies in its ability to overcome the limitations of traditional approaches in terms of mandible height and pedicle length, while optimizing both functional and esthetic outcomes.The technique utilizes a combination of single-double-single barrel fibula segments to achieve ideal esthetics and support for dental prosthesis across different areas of the mandible. At the chin, a double barrel design provides proper chin and lower lip projection and supports dental prosthesis at the alveolus, while single barrel segments are used for the mandibular bodies to allow adequate restorative space for dental rehabilitation and save the pedicle length.Favorable outcomes were demonstrated in terms of flap survival, dental implant osseointegration, bony healing, facial aesthetics, and occlusal rehabilitation. By addressing both functional and aesthetic requirements, this technique represents an important advancement in mandibular reconstruction for complex Brown Class III defects. The approach showcases the potential of computer-assisted surgery and innovative flap designs to improve patient outcomes in challenging reconstructive scenarios.

Background: Ideal methods for double eyelid crease creation in Asian upper eyelids remain controversial due to the complexity of Asian upper eyelid anatomies. Key confusions include the underestimation of tarsal height and the septum/aponeurosis fusion point height (FPH), which may underlie the unnaturally high creases in many classic double eyelid procedures.

Methods: A total of 1272 patients had tarsal heights measured. Among 386 patients with orbital septa opened, FPHs and other anatomic findings were also documented. Based on the anatomical findings, a novel method for double eyelid crease formation was designed. This method involves preserving the pretarsal fibrofatty tissue and using horizontal mattress sutures to connect the orbicularis oculi muscle (OOM), through the pretarsal fibrofatty tissue and levator aponeurosis, to the pretarsal membrane (MAP method) as the linkage mechanism.

Results: Tarsal height levels were higher than reported in many previous studies. In the supine position, all FPHs were higher than the tarsi. Eyelid creases using the MAP method are created below the superior tarsal edges at varying heights, accommodating individual patient requests while achieving well-formed creases and improved eyelid mechanics. The recovery was brief, and the results were long-lasting with a minimal failure rate.

Conclusions: Tarsal heights and FPHs are not as low as previously thought, which could explain why many 'classic' surgeries encounter various issues. Our proposed MAP method for Asian double eyelid blepharoplasty allows conservative crease-height-adjustability with results that are dynamic, natural, and durable.

Background: Despite the existence of cleft and craniofacial teams approved by the American Cleft Palate and Craniofacial Association (ACPA), access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. The authors investigated the geospatial relationship between US counties and ACPA-approved centers.

Methods: The geographic location of all ACPA-approved cleft and craniofacial centers in the United States was identified. Distance between individual US counties ( n = 3142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with US Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t tests and analysis of variance.

Results: Over 40% of US counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius ( n = 1267) versus 29% for cleft teams ( n = 909). Over 90% of counties greater than 100 miles from a craniofacial team had a population less than 7500 ( n = 1150). Of the counties more than 100 miles from a cleft team, 64% had a child poverty rate greater than the national average ( n = 579). Counties with the highest birth rate and more than 100 miles to travel to an ACPA team are in the Mountain West.

Conclusions: Given the time-sensitive nature of operative intervention and access to multidisciplinary care, the lack of equitable distribution in certified cleft and craniofacial teams is concerning. Centers may better serve families from distant areas by establishing satellite clinics, conducting telehealth visits, and training local primary care providers in referral practices.

Background: Although the number of female physicians in the United States has been increasing, most practicing surgeons in the United States are men. By contrast, Indonesia has achieved notable gender parity among surgeons, with the number of women practicing as plastic surgeons projected to soon surpass that of men. Achieving greater female representation in plastic surgery is important for delivering high-quality care, especially in the face of physician shortages and high burnout rates.

Methods: This survey study was conducted at the 26th annual scientific meeting of the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeons, in Manado, Indonesia, in August 2023. Respondents were asked about their perceptions of plastic surgery, mentorship, career motivations, and caregiving responsibilities. Responses were scored using a 3-point Likert scale of agreement with statements (disagree, neutral, or agree); χ 2 and Fisher exact tests were performed to assess differences in responses by sex.

Results: In this validated survey of 175 plastic surgeon trainees and attendings, there were no significant differences between sexes in the perception and roles of mentorship in preparing for a career in plastic surgery. Respondents from both sexes espoused optimistic views on work-life balance items, including time for family and friends and flexibility of work schedules.

Conclusions: Indonesia can serve as a model for encouraging greater gender parity in plastic surgery. Community-level interventions, such as family leave policies, childcare provisions, and initiatives to promote an inclusive culture, will create a more supportive workplace to increase women's representation in plastic surgery in the United States and around the world.

Background: A relationship between nerve and osseous regeneration has been described. During the surgical treatment of symptomatic neuroma in transtibial amputees, the authors have found that heterotopic ossification (HO) depicted on preoperative radiographs appeared to be associated with the location of symptomatic neuromas in both the peroneal and tibial nerve distributions.

Methods: Data were collected for transtibial amputees who underwent surgical management of symptomatic neuroma and were prospectively enrolled from 2018 through 2023. Preoperative radiographs were assessed for the presence of HO located at the distal fibula and tibia. The presence of a peroneal or tibial neuroma was based on findings contained within the operative reports. Pain levels were measured on a numeric rating scale (0 to 10).

Results: Sixty-five limbs of 62 amputees were included. Peroneal neuroma and presence of fibular HO ( P = 0.001) and tibial neuroma and presence of tibial HO ( P = 0.038) demonstrated an association. The odds of having a symptomatic peroneal neuroma with fibular HO present were greater than the odds of a symptomatic peroneal neuroma when fibular HO was absent (OR, 9.3 [95% CI, 1.9 to -45.6]; P = 0.006). Preoperative pain scores were significantly higher for all patients with HO ( P < 0.001), those with fibular HO ( P < 0.001), and those with tibial HO ( P < 0.001), compared with patients without HO.

Conclusions: In patients with symptomatic neuromas, preoperative pain was worse when HO was present in the transtibial amputee's residual limb. Further research on the neuroma-HO complex in symptomatic amputees is required.

Clinical question/level of evidence: Risk, III.

Background: The purpose of this study was to compare the outcomes of 2 types of tarsoconjunctival pedicle flaps for reconstruction of large lower eyelid defects.

Methods: The authors performed a retrospective medical record review of consecutive patients who underwent centrally or laterally based tarsoconjunctival pedicle transconjunctival flap for lower eyelid reconstruction for defects greater than 50% of the lid margin. Full-thickness skin grafts were used for anterior lamellar reconstruction in all cases. The primary outcome measure was eyelid position, function, and satisfactory appearance.

Results: A total of 43 patients were identified. Twenty-six patients underwent reconstruction with a centrally based tarsoconjunctival pedicle flap; 17 patients underwent reconstruction with a laterally based tarsoconjunctival pedicle flap. The average size of the lid defect was 77.7% (range, 50% to 100%) in the central group and 75% (range, 50% to 100%) in the lateral group ( P = 0.604). Mean follow-up time was 61.5 weeks in the central group and 46.6 weeks in the lateral group ( P = 0.765). After division of the flap and during follow-up, 27% of the centrally based group required revisional surgery, versus none in the laterally based group ( P = 0.03). All the patients with centrally based flaps required second-stage flap division, whereas only 52% of patients with a laterally based flap underwent second-stage flap division ( P < 0.001).

Conclusion: For reconstruction of large lower lid defects requiring lid-sharing procedures, centrally and laterally based procedures had equivalent functional outcome, but the laterally based group had less need for revisional procedures and may not need a second-stage division of the flap.

Clinical question/level of evidence: Therapeutic, III.