Plastic and reconstructive surgery最新文献

Summary: The Pitanguy ligament is a crucial structure in nasal tip support and in maintaining the integrity of the soft-tissue envelope of the nose. In this cadaveric study, the authors dissected out the Pitanguy ligament on a series of fresh human cadaver specimens to elucidate the structure of the ligament and its fate in open rhinoplasty. The Pitanguy ligament can act as a tethering force to the nasal tip when reshaping the nasal tip. Release of the Pitanguy ligament alleviated downward tension on the nasal tip, and tip shaping to a more appropriate position demonstrated that this ligament was displaced from its ideal position. In patients seeking rhinoplasty, this structure may require release and reconstruction to successfully alter tip position and avoid supratip deformity.

Background: Breast reconstruction following mastectomy is underused in the United States. Evidence suggests that more competitive hospital markets offer increased access to procedural care across specialties. This study aimed to determine the impact of regional plastic surgeon competition on use, outcomes, and cost of breast reconstruction following mastectomy for breast cancer.

Methods: The authors conducted a retrospective cross-sectional analysis using MarketScan claims data from 2009 to 2020. The Herfindahl-Hirschman Index, a measure of market concentration, was calculated using the sum of squares of the proportion of breast reconstruction cases performed by each surgeon in a metropolitan statistical area. Multivariable logistic regression was used to identify differences in rates, outcomes, and costs of reconstruction by the Herfindahl-Hirschman Index.

Results: Odds of receiving breast reconstruction within 2 years of mastectomy were higher for those in moderately competitive (OR, 1.51 [95% CI, 1.37 to 1.66]; P < 0.001) or competitive (OR, 1.71 [95% CI, 1.58 to 1.86]; P < 0.001) regions compared with noncompetitive regions. Patient out-of-pocket costs decreased when comparing moderately competitive regions with noncompetitive regions (-$67.38 [95% CI, -$88.65 to -$46.11]; P = 0.007), and decreased further when comparing competitive with noncompetitive regions (-$113.06 [95% CI, -$137.00 to -$89.12]; P = 0.02). No linear association between total, surgeon, or facility cost and market competition strata was identified.

Conclusions: Greater competition among surgeons is associated with improved access to reconstructive surgery, but no difference in cost. Application of this evidence may include system-level strategies to bolster care coordination, while targeting drivers of cost, such as hospitals and hospital systems, through policy.

Background: Rhinoplasty is one of the most commonly performed facial operations in the United States, and many major and minor nasal tip support structures affect tip projection. Overprojection may result from anatomical factors or occur iatrogenically during primary rhinoplasty. Achieving reliable, reproducible, and stable results is the aim of nasal tip deprojection rhinoplasty. The authors' technique is designed to decrease nasal tip deprojection in patients with an overly projected nasal tip.

Methods: A retrospective chart review of 2003 rhinoplasty cases in the senior author's (R.G.R.) practice was conducted for the period between July of 2014 and June of 2022. The inclusion criteria were cosmetic or functional rhinoplasty cases with nasal tip deprojection, with a minimum of 12 months of follow-up. Outcomes of interest included the rate of operative revisions and the rate of postoperative infection.

Results: A total of 447 patients met the inclusion criteria. The mean age of our study group was 32.1 years, with 409 female patients, and 291 cases were primary rhinoplasties. The mean follow-up period was 22.4 months. Eight patients (1.8%) required empiric antibiotics postoperatively, and 17 patients (3.8%) required operative revision.

Conclusions: The authors' case series demonstrates that combining resection of the medial crura with lateral crural steal and a columellar strut graft allows the surgeon to achieve considerable nasal tip deprojection. The comprehensive patient follow-up (mean, 22.4 months) further supports the reliability of the authors' technique.

Clinical question/level of evidence: Therapeutic, IV.

Background: The aim of this study was to conduct a comparative analysis, using computed tomographic scans, of ossification patterns in unilateral cleft lip and palate patients who underwent early secondary gingivoalveoloplasty (esGAP) versus those who underwent traditional alveolar bone grafting harvested from the iliac crest (IC).

Methods: Computed tomographic scans of 22 consecutively treated patients with esGAP were compared with those of 21 patients treated with bone grafting from the IC. Inclusion criteria were nonsyndromic unilateral cleft lip and palate patients in permanent dentition. Two parameters were considered: the alveolar thickness, measured at 3 levels, and the nasoalveolar height. All measurements were normalized and ratios of the affected versus nonaffected sides were provided as in addition to the statistical comparison between the 2 groups' ossification outcomes.

Results: In the esGAP sample, nasoalveolar height was categorized as ideal and good in 86.36% and in 13.64% of the cases, and no mediocre or insufficient ossification was detected; whereas in the bone grafting sample, 38.10% had ideal and good ossification, 14.29% had mediocre ossification, and 9.52% had insufficient ossification. As regards the alveolar thickness, when we consider the average of 3 levels, the esGAP sample was ideal and good in 57.57% and in 30.30% of the cases; for the IC sample, the alveolar thickness was ideal and good 41.27% and in 25.40% of the cases, respectively. The analysis detected a statistically significant difference in the ossification outcomes in the 2 samples.

Conclusion: The esGAP yields superior ossification grades in comparison to IC bone grafting.

Clinical relevance statement: In unilateral cleft lip and palate patients, esGAP seems to allow for a higher grade of ossification compared to IC bone grafting.

Clinical question/level of evidence: Therapeutic, III.

Background: Inferior lymphatic vessel (LV) quality was thought to be associated with prolonged lymphedema duration (LD), which can lead to unfavorable lymphaticovenous anastomosis (LVA) outcomes. However, increasing evidence supports the use of LVA in the treatment of advanced lymphedema. Hence, this study aimed to determine the impact of LD on LV quality and outcomes after LVA in patients with secondary lower limb lymphedema.

Patients and methods: A total of 189 patients who underwent supermicrosurgical LVA were retrospectively reviewed and enrolled. The study group (LD>3.6 years) and the control group (LD≤3.6 years) consisted of 94 and 95 patients, respectively. Patients with previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, functional parameters and volume changes were recorded and the parameters except LD were matched using propensity-score-matching. The primary endpoint was volume change at 6 and 12 months after LVA.

Results: Before matching, the study group had significantly higher ratios of indocyanine green-enhanced, lymph flow-positive, and Normal+Ectatic LVs (p=0.016, 0.035, and 0.002, respectively) than the control group. After all parameters except LD were matched, 64 patients were included in each group, with higher median LD in the study group (7.8 vs. 1.1 years, p<0.001) than the control group. However, no significant intergroup differences were found in postoperative percentage volume reduction at the 6- and 12-month follow-up (p=0.813 and 0.627, respectively).

Conclusion: Contrary to common beliefs, longer LD did not negatively affect LV quality and outcomes after LVA. Therefore, LVA remains a viable treatment option for patients with long-standing lymphedema.

Background: Silicone nasal implants have been widely used in rhinoplasty. However, research on the correlation between implant hardness and the development of fibrosis and inflammation is lacking. This study investigated how the hardness of silicone implants influences fibrosis and inflammation through an experimental investigation.

Methods: Three types of nasal silicone implants with varying hardness levels were implanted bilaterally on the backs of 15 Wistar rats. Ten weeks post-implantation, clinical aspects, such as differences in immune reactions and formation of peri-implant capsules were analyzed. The intra-tissue response of the host was assessed by qRT-PCR using 11 markers. Specific markers were investigated by immunohistochemical (IHC) staining. Pathological grading was performed to investigate inflammation and fibrosis in the peri-implant tissues. Quantification and statistical analysis of these parameters were conducted to derive scores for intergroup comparisons.

Results: Histological analysis of the 45 capsules obtained revealed lower levels of fibrosis and acute inflammation in the group with lower hardness. This result was confirmed by IHC staining. Hematoxylin and eosin staining showed that the capsule thickness was less in the low-hardness group. Additionally, inflammation resolved quickly in the low-hardness group, and mature fibrotic tissue was observed.

Conclusions: When silicone implants are stably positioned within the body, less-rigid implants exhibit lower inflammatory or fibrotic responses. This is directly related to the adverse effects associated with capsule formation. These findings contribute to our understanding of the behavior of heterotopic materials in the nasal dorsum and their effects on the skin and soft tissue envelope.

Background: The supratip break point is paramount in nasal aesthetics. "Polly beak deformity" denotes a swollen supratip, posing aesthetic concerns. The Pitanguy ligament facilitates tissue attachment and aids in the control of fibrosis. This study investigated the impact of Pitanguy ligament repair on the supratip depth.

Patients: This retrospective study conducted between May 2019 and July 2023 included 120 patients. Divided into three groups, each comprising 40 patients: Group I (No Touch Group): The Pitanguy ligament remained untouched. Group II (Excision Group): The Pitanguy ligament was excised. Group III (Repair Group): The Pitanguy ligament was sutured to the highest point of the caudal septum. Patient photographs were taken at the 3rd and 12th months post-operation. Supratip area depth was measured using Adobe Photoshop software. Changes in the supratip breakpoint depth at 3 and 12 months, along with a comparison of the 12-month supratip depths among the groups, were conducted.

Results: The study included 120 patients (96 females and 24 males. Group II exhibited statistically significant differences when comparing the changes between 3 and 12 months postoperatively (p<0.05). By the 12th month, the depth of the repair group (Group III) significantly exceeded that of the other groups (p<0.05).

Conclusion: This study demonstrates that performing Pitanguy repair in open rhinoplasty techniques significantly enhances supratip depth and prevents pollybeak deformities.

Introduction: Type A ulnar/postaxial polydactyly describes a well-developed supernumerary small finger, which may have self-image and functional sequelae even after reconstructive surgery. We aimed to characterize postoperative outcomes and substantiate the CoULD Ulnar Polydactyly (CUP) Classification's clinical relevance.

Methods: All cases at two major pediatric hospitals from 2012-2022 were reviewed. Surgeons classified preoperative radiographs using the CUP Classification. Complication rates were compared using Chi-square/Fisher's exact tests. Patient-reported outcomes included the Patient and Observer Scar Assessment Scale, Australian Hand Difference Register aesthetics scale, and PROMIS; descriptive analyses considered minimum clinically important differences (MCIDs).

Results: Sixty-four hands in 42 patients underwent surgery (mean age 15.1 ± 12.2 months). Operative techniques aligned with the CUP reconstructive pathway. Late complications varied significantly by CUP subtype (P < .001), occurring most commonly in A3-Divergent Metacarpophalangeal and A5-Duplicated Metacarpal cases. Differences centered on functional complications, including subjective functional concerns, flexion contractures, and limited flexion (each P ≤ .02). Nineteen patients/caregivers completed questionnaires on average 5.9 years postoperatively. Most agreed that surgery improved their hands' appearance (median 5/5) and endorsed happiness with their hands' appearance (median 4/5). Approximately half nonetheless felt that their hands could look better. Patients/caregivers reported good scar quality. Regarding function, mean PROMIS Upper Extremity scores fell more than a MCID below pediatric norms, especially for older children/adolescents (ages 8-18 years). Self-reported PROMIS Peer Relationships were within normal limits.

Conclusions: Most patients were pleased with postoperative results, but many reported room for aesthetic and functional improvement. This study corroborated the CUP Classification's clinical relevance.