Plastic and reconstructive surgery最新文献

Background: Tissue expansion for treating giant congenital melanocytic nevi (GCMN) is a commonly used surgical method. However, the procedure's efficacy is often hindered by anatomical and histologic characteristics and blood supply, particularly in the extremities and trunk. Enhancing expansion efficiency while reducing complications is thus a topic to be investigated, especially for pediatric patients undergoing rapid physical and psychological development with higher risks of noncompliance to medical instructions. The purpose of this study was to explore the effectiveness of expansion in extremities and trunk by immobilizing the acellular dermal matrix (ADM) in the gravitational force zone of inflating expanders.

Methods: All patients involved in this research underwent ADM-assisted tissue expansion in either the extremities or trunk. ADM was fully flattened, securely fixed to the lower pole of the expander, and subsequently attached to the inner surface of the expanding flap.

Results: From 2021 to 2023, a total of 9 pediatric patients with GCMN underwent ADM-assisted tissue expansion. All patients achieved the desired expansion volume without experiencing petechiae, ecchymosis, or skin ulceration in the ADM-covered area. The process was well tolerated by all patients, with no reports of itching, pain, allergic reaction, or fever. During the flap transfer, the ADM was observed to be firmly adhered to the expanding flap with discernible capillary network.

Conclusions: ADM-assisted tissue expansion demonstrates promise in augmenting expansion efficiency and reducing the time needed for surgical intervention in the extremities and trunk, thereby presenting significant clinical value for pediatric patients with GCMN.

Clinical question/level of evidence: Therapeutic, IV.

Background: Root-level suprascapular nerve palsy is commonly reconstructed by means of spinal accessory nerve transfer in brachial plexus injury, but some patients do not recover. The authors hypothesize that this relates to concomitant undetected lesions distal to the nerve transfer coaptation.

Methods: A total of 67 patients with plexus injury and C5/C6 root involvement were included in this prospective study between March of 2021 and October of 2022. During spinal accessory to suprascapular nerve transfer, the entire suprascapular nerve was explored using cresenteric clavicular osteotomy, and anatomic variations and injury patterns categorized.

Results: Proximal root involvement was C5 to C6 ( n = 8), C5 to C7 ( n = 13), C5 to C8 ( n = 17), or C5 to T1 ( n = 29). Mean time from injury to surgery was 5.6 months. The suprascapular nerve was found to be injured in 16 of 67 cases (24%). In 9 cases (13%), the lesion was proximal to the suprascapular fossa. In 3 cases (4%), the suprascapular nerve was injured both proximally and within the fossa, and in 4 cases (6%), in the fossa or distal to it. Therefore, in 7 cases (10%), a traditional suprascapular nerve transfer would not successfully bypass the zone of injury of the suprascapular nerve in the fossa. Of the 16 cases of concomitant suprascapular nerve injury, 1 of 8 in occurred in C5 to C6 root injury, 4 of 13 of C5 to C7 root injury, 5 of 17 of C5 to C8 root injury, and 6 of 39 in total paralysis.

Conclusions: Concomitant distal suprascapular nerve injury in brachial plexus stretch palsy occurred in 24% of the cases. This warrants attention from the surgeon to identify distal lesions and to perform the nerve transfer beyond any secondary lesions.

Background: Nerve xenografts harvested from transgenic α1,3-galactosyltransferase knockout pigs lack the epitope responsible for hyperacute rejection in pig-to-primate transplants. It is unknown whether these cold-preserved nerve grafts support axonal regeneration in another species during and after immunosuppression. The authors compared outcomes between autografts and cold-preserved xenografts in a rat sciatic model of nerve gap repair.

Methods: Fifty male Lewis rats had a 1-cm sciatic nerve defect repaired using autograft and suture ( n = 10); 1-week or 4-week cold-preserved xenograft and suture ( n = 10 per group); or 1-week or 4-week cold-preserved xenograft and photochemical tissue bonding using a human amnion wrap ( n = 10 per group). Rats with xenografts were given tacrolimus until 4 months postoperatively. At 4 and 7 months, rats were killed and nerve sections were harvested. Monthly sciatic functional index (SFI) scores were calculated.

Results: All groups showed increases in SFI scores by 4 and 7 months. The autograft suture group had the highest axon density at 4 and 7 months. The largest decrease in axon density from 4 to 7 months was in the group with 1-week cold-preserved photochemical tissue bonding using a human amnion wrap. The only significant difference between group SFI scores occurred at 5 months, when both 1-week cold-preserved groups had significantly lower scores than the 4-week cold-preserved suture group.

Conclusions: The results suggest that α1,3-galactosyltransferase knockout nerve xenografts may be viable alternatives to autografts. Further studies of long-gap repair and comparison with acellular nerve allografts are needed.

Clinical relevance statement: This proof-of-concept study in the rat sciatic model demonstrates that cold-preserved α1,3-galactosyltransferase knockout porcine xenografts support axonal regeneration and viability following immunosuppression withdrawal. These results further suggest a role for both cold preservation and photochemical tissue bonding in modulating the immunological response at the nerve repair site.

Background: Each breast augmentation technique has advantages and indications, and the quest for the perfect implant pocket plane is ongoing. An ideal dual plane should meet 3 requirements: adequate implant coverage, optimal control of breast shape, and maximal muscle preservation. The authors report a modified procedure for breast augmentation: the subfascial mini-muscle release dual-plane technique.

Methods: From an inframammary or periareolar approach, the implant pocket is dissected in a subfascial plane up to the pectoralis major muscle. The muscle is split 3 cm above the lateral margin, and then pocket dissection proceeds in the submuscular plane. A small portion of the costal origin is divided inferomedially to create a dual plane.

Results: This study included a total of 178 patients with hypoplasia or breast atrophy, among whom 34 had breast ptosis and 20 had tubular breast deformity. The median follow-up period was 20 months. The average implant volume was 268.8 mL, and a smooth implant was used in 85.4% of cases. There was 1 case of hematoma, 2 cases of wound-healing issues, 2 cases of rippling, 2 cases of grade III or IV capsular contracture, 5 cases of implant malposition, and 12 cases of mild muscle contraction-associated deformity. Revision procedures were performed on 2 patients.

Conclusions: The subfascial mini-muscle release dual-plane technique is an easy method of breast augmentation, and it is especially indicated for ptotic breasts and tubular breast deformities. This technique combines the advantages of traditional dual-plane and muscle-splitting techniques, yielding a satisfactory aesthetic outcome.

Clinical question/level of evidence: Therapeutic, IV.

Background: The use of postmastectomy radiation therapy (PMRT) in the setting of immediate 2-stage breast reconstruction is becoming increasingly widespread. However, the timeframe of tissue expander exchange for permanent implant placement following PMRT is not well defined, and it remains unclear what time interval optimizes surgical outcomes and patient satisfaction.

Methods: A systematic review conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 was completed. The PubMed, Embase, Scopus, and Cochrane databases were searched under keywords pertaining to concepts of tissue expander breast reconstruction and PMRT. Inclusion criteria encompassed primary articles on tissue expander breast reconstruction with adjuvant radiation therapy reporting timing of exchange to permanent implant following radiation therapy and surgical outcomes.

Results: Of the initial 1259 publications, 15 studies met our inclusion criteria, and 11 studies had granular enough data to use for pooled analysis. Implant exchange less than 6 months after PMRT was found to be associated with increased incidence of wound dehiscence (17.12% versus 3.64%; P < 0.001) and hematoma (25% versus 2.59%; P < 0.001) compared with exchange after 6 months. There was no significant difference in incidence of surgical-site infection, seroma, capsular contracture, or reconstructive failure.

Conclusions: Expander-to-implant exchange at less than 6 months is associated with a higher incidence of wound dehiscence and hematoma formation but does not increase the risk of reconstruction failure. The limited research on ideal timing prompts further investigation to optimize surgical outcomes for the increasing patient population undergoing PMRT and immediate 2-stage breast reconstruction.

Background: Restrictive policies on termination of pregnancy (TOP) may lead to more infants with congenital abnormalities. This study aimed to assess the association between statewide enactment of TOP restriction and cleft lip and/or palate (CL/P) incidence, and to identify mediating demographic characteristics.

Methods: The authors examined state-specific trends in CL/P incidence in infants before and after implementation of laws restricting TOP in Michigan compared with New York, where no such laws were passed. The percentage change of CL/P incidence per 1000 live births in postpolicy years (2012 to 2015) compared with prepolicy years (2005 to 2011) was compared, with adjustments for confounding factors in multivariate models.

Results: The incidence of CL/P changed significantly in Michigan (19.1%) compared with New York (-7.31%). Adjusting for sex, race/ethnicity, median household income level, and expected payer, the adjusted percentage difference between Michigan and New York was 53.3% ( P < 0.001). Stratification by race/ethnicity and median household income demonstrated that changes were only significant among Black (139%; P < 0.001) and Hispanic (125%; P = 0.045) patients and among those from the lowest (50.3%; P < 0.001) and second lowest (40.1%; P = 0.01) income quartiles.

Conclusion: The authors' research, combined with the recent Supreme Court decision in Dobbs v Jackson Women's Health Organization allowing states to place further restrictions on TOP, suggests that more infants in the future will be born in need of treatment for CL/P.

Summary: Obesity is one of the greatest public health concerns in the United States and has reached an epidemic scope over the past few decades. Plastic surgery in patients with obesity has been linked to higher complication rates both before and after weight loss. This article discusses the evolution and landscape of antiobesity medications as they apply to plastic surgery. Although bariatric surgery has been effective in long-term treatment, new pharmacologic advances in glucagon-like peptide-1 agonists, such as semaglutide, have demonstrated promising effectiveness. These medications pose several unique challenges, particularly with regard to perioperative management and risk of weight regain after discontinuation. An understanding of these new pharmacologic agents is crucial for plastic surgeons, who treat patients with obesity.