Plastic and reconstructive surgery最新文献

Background: Crooked nose deformities remain a surgical challenge due to complex asymmetries of bony and cartilaginous structures. The "Hybrid Technique" combines preservation and structural rhinoplasty principles to improve correction while maintaining procedural efficiency.

Methods: A retrospective study was performed on 54 patients who underwent primary rhinoplasty for crooked nose correction between January 2023 and June 2024. The first 28 consecutive patients were treated with the Pisa Tower technique, and the subsequent 26 with the Hybrid Technique. Baseline demographic and clinical characteristics were comparable between groups. Objective outcomes included nasal axis deviation and R-Webster triangle symmetry measured from standardized photographs and CT scans by two blinded reviewers. Functional results were assessed using the NOSE questionnaire at 12 months.Postoperative changes were analysed using linear regression models adjusted for baseline values, and standardized effect sizes with 95% confidence intervals were calculated to quantify between-group differences. Operative time and postoperative complications were also recorded.

Results: Both techniques achieved significant improvement in nasal alignment (p < 0.001). Mean nasal deviation decreased from 8.1° to 1.6° in the Hybrid group and from 7.6° to 1.4° in the Pisa Tower group (p > 0.05). NOSE scores improved markedly in both cohorts (Hybrid: 76.8 → 19.4; Pisa Tower: 74.9 → 21.1; p < 0.001). Postoperative changes in nasal axis deviation and R-Webster triangle symmetry did not differ between groups (p > 0.05). Adjusted effect sizes were small with confidence intervals crossing zero (e.g., nasal axis deviation d = -0.18, 95% CI -0.73 to 0.37), confirming the absence of meaningful between-group differences. NOSE scores improved similarly in both cohorts, and operative time and complications were comparable. Operative time was comparable (119 vs. 122 minutes; p = 0.42). Minor dorsal hump recurrence occurred in one Hybrid and three Pisa Tower cases, with no revisions required.

Conclusions: The Hybrid Technique provides reproducible correction of nasal asymmetry with functional outcomes, complication rates, and operative times comparable to the Pisa Tower approach, representing a versatile option for complex nasal deviations.

We define "BBL blowout deformity" as a soft tissue deformity after autologous gluteal fat transfer. It is caused by a loss of integrity of the fascia and ligaments in the buttocks, resulting in an undesirable convexity and weakening of the lower buttock skin. A fat necrosis cyst is often found within the deformity that must be addressed for correction. Treatment guidelines are not currently defined; thus, we have created a treatment algorithm that may serve as a preliminary guide. Generally, patients with favorable factors such as younger age (<35), good skin quality, and a smaller deformity of <20% buttock surface area can tolerate a more conservative approach. For these patients, a liposuction cannula can be used to evacuate the fat necrosis cyst, fenestrate the cyst capsule, and perform a wide soft tissue release, which can achieve good correction of the deformity. Those with older age (>35), poor skin quality, or larger deformity of >20% buttock surface area are recommended to be treated with direct skin and fat necrosis cyst removal through a direct buttock-lift incision. Invasive radiofrequency skin tightening may be added in all cases to improve results. These single-surgeon clinical observations informed our proposed treatment algorithm.

Background: Housing instability significantly impacts surgical outcomes, with studies showing increased complications and mortality. However, research has primarily focused on emergent and urgent procedures rather than elective surgeries like breast reconstruction. A better understanding of the relationship between housing instability and surgical outcomes in the elective setting can inform strategies to provide more comprehensive, holistic care. Therefore, we sought to determine whether implant-based breast reconstruction can be safely performed in patients with housing instability.

Methods: We conducted a retrospective cohort study using the PearlDiver Mariner claims database (2017-2023) of adult females undergoing implant-based breast reconstruction. Our exposure was housing instability, defined by ICD-10 Social Determinants of Health Z-Codes. Our primary outcome was 90-day surgical complications. Secondary outcomes included medical complications, readmissions, length of stay, and reconstructive failure.

Results: 562 (0.6%) patients had coded housing instability. Patients with housing instability demonstrated higher rates of chronic medical conditions, anxiety, depression, and recent tobacco use. Housing instability was associated with increased rates of 90-day surgical complications (18.1% vs 10.7%; P<.001), 90-day medical complications (11.2% vs 4.4%; P<.001), 30-day readmission rates (5.5% vs 2.6%; P<.001), and one-year reconstructive failure rates (9.8% vs 6.2%; P<.001). After adjusting for mental health, tobacco use, and comorbidities, there was no significant difference in surgical complications, readmission rates, or reconstructive failure compared to patients without housing instability.

Conclusions: Comorbidity burden and modifiable health behaviors appear to be primary drivers of increased complications among patients with housing instability; however, appropriate preoperative optimization may enable safe breast reconstruction without elevated risk.

Background: Sensory loss following reduction mammaplasty remains a key concern for patients. While general tactile recovery has been well studied, less is known about temperature sensation or region-specific recovery patterns. This study evaluates tactile and thermal sensory recovery across the breast and identifies clinical and operative predictors of postoperative sensory loss.

Methods: A prospective cohort study was conducted at our institution and enrolled patients undergoing bilateral reduction mammaplasty using a superior or superomedial pedicle and Wise-pattern incisions. Tactile sensation was measured using a pressure-specified device, and thermal sensation was assessed via heat and cold detection. Testing was performed preoperatively, and at 1 month and 3-6 months postoperatively. Linear and logistic regression analyses were used to identify predictors of sensory loss, including age, BMI, and resection weight.

Results: Forty-nine patients (98 breasts) were included. Tactile sensation worsened significantly at the NAC and inner breast at 1 month but returned to baseline by 3-6 months. Thermal sensation at the NAC and inferior breast remained impaired at 3-6 months. Resection weight predicted early tactile loss, while BMI and age were associated with early thermal deficits. At 3-6 months, higher BMI-but not resection weight-remained a predictor of persistent tactile loss. No long-term predictors of thermal sensation were identified.

Conclusion: Tactile and thermal recovery follow distinct patterns after breast reduction. Resection weight affects short-term tactile outcomes, while higher BMI predicts long-term tactile impairment. These findings support personalized patient counseling to guide postoperative patient expectations.

Background: The spinal accessory nerve (SAN) is particularly vulnerable to iatrogenic injury during head and neck procedures, especially in the posterior cervical triangle where it courses superficially. Despite its clinical relevance, reliable surface-based strategies for SAN localization remain underdeveloped, particularly in the context of aesthetic and limited-access surgeries.

Methods: A cadaveric study was conducted on 186 hemi-necks from 111 Thiel-embalmed cadavers to identify consistent anatomical relationships between the SAN and four readily palpable skeletal landmarks: the mastoid process, sternoclavicular joint, midclavicular point, and acromioclavicular joint. Linear distances from the SAN's emergence at the posterior border of the sternocleidomastoid muscle to each landmark were measured, and a reproducible "danger zone" was mathematically defined.

Results: The SAN was reliably identified in all dissections. The mean distances from the nerve to the mastoid process, sternoclavicular joint, midclavicular point, and acromioclavicular joint were 5.1 cm, 11.0 cm, 9.1 cm, and 12.8 cm, respectively. A circular danger zone with a mean diameter of 2.96 cm (6.9 cm² area) was calculated based on overlapping standard deviations. When focusing solely on the mastoid process as the most consistent reference, a refined zone of 1.98 cm diameter (3.1 cm²) was delineated.

Conclusion: This study defines a clinically relevant and reproducible surface-based danger zone for SAN localization in the posterior cervical triangle. Anchored to palpable skeletal landmarks and validated on a large anatomical dataset, the proposed model enhances surgical safety during oncologic and aesthetic neck procedures by facilitating preemptive nerve identification.

This national projection study evaluates the future supply and demand of plastic surgeons in the United States through 2037 using the Health Workforce Simulation Model from the Health Resources and Services Administration. Workforce supply was modeled in full-time equivalents (FTEs), accounting for residency graduation rates, attrition, and retirement patterns through scenario-based sensitivity analysis across alternative workforce assumptions. Demand projections incorporated demographic trends, service utilization, and physician-to-population ratios. Under status quo assumptions, the national supply of plastic surgeons is projected to decline by approximately 22%, from 10,960 FTEs in 2022 to 8,540 by 2037. In contrast, demand is expected to increase by nearly 6% under baseline conditions and by more than 40% if access barriers are eliminated. This imbalance translates into a national adequacy decline from 100% in 2022 to 73% by 2037, with the most pronounced disparities in nonmetropolitan regions and in states such as Arkansas, Maine, and New Mexico, which are projected to have the lowest adequacy levels. This projected shortage represents a multifactorial challenge shaped by demographic aging, geographic maldistribution, constrained rural infrastructure, and reimbursement pressures. Addressing these trends will require coordinated, data-driven interventions supported by sound policy planning. Policy initiatives should emphasize equitable surgeon distribution, targeted financial incentives in underserved regions, protection of procedural scope, and the adoption of technological innovations to enhance equitable and sustainable access to plastic surgery care across the United States.

Background: In autologous breast reconstruction, the internal mammary artery is the preferred recipient vessel. Although rib-resecting is usually performed, the rib-preserving technique has gained increasing attention in recent years without being scientifically evaluated.

Methods: In our retrospective study, we analyzed 234 autologous breast reconstructions performed between 2018 and 2023 at a single hospital, comparing 163 patients who underwent rib resection with 71 patients who received the rib-preserving technique. Intraoperative data, postoperative pain medication usage, and follow-up interventions over a minimum of one year were screened.

Results: Ischemia time was significantly shorter in the rib-resecting group (45:00 min, IQR 37:44-60:00) compared with the rib-sparing group (50:59 min, IQR 43:59-71:00; p = 0.006). However, the rib-sparing group had longer pedicle lengths (11, IQR 10-12 vs. 10, IQR 9.5-11 cm; p = 0.074) and larger arterial diameters (p = 0.084). Postoperatively, rib-resecting patients required longer opioid treatment (3, IQR 2-4.25 vs. 2.5, IQR 1.63-3 days; p = 0.019), reported greater pain on the first postoperative day (p = 0.049), and exhibited more blood loss and drainage volume (p = 0.033, p = <0.001). Follow-up procedures were more frequent in the rib-resecting group (1, IQR 1-3) than in the rib-sparing group (1, IQR 0-1; p = 0.001), including lipofilling (35% vs. 20.3%, p = 0.029).

Conclusion: The rib-sparing approach shows significant advantages over rib-resection, particularly in terms of reduced postoperative morbidity and more aesthetically pleasing result with fewer secondary interventions. When technically feasible, it should be considered the preferred method in autologous breast reconstruction.Clinical Question/Level of Evidence.

Lymphatics System Transfer (LYST) is a recently described technique that combines the benefits of the established Vascularized Lymph Node Transfer (VLNT) with the advantages of Vascularized Lymph Vessel Transfer (VLVT). This procedure involves harvesting vascularized tissue that includes superficial lymphatic vessels and their corresponding draining nodes and transferring the tissue flap to the upper or lower extremity by microsurgical anastomosis. We present a novel pedicled LYST technique utilizing a Superficial Circumflex Iliac Perforator (SCIP) flap to treat patients with lower extremity lymphedema and concomitant chronic venous disease. Six patients underwent pedicled SCIP LYST, five of whom also received lymphovenous bypass distally in the lower extremity. Average follow-up period was 31 weeks (range: 10-55 weeks). Postoperative outcomes included a mean 15-point reduction in Lymphedema Life Impact Scale (LLIS) score (0.5 point per week) and a mean 30-unit decrease in bioimpedance spectroscopy (L-dex) measurements (0.9 units per week). No immediate complications were reported. The inclusion of long afferent lymphatic vessels with their draining lymph nodes may reduce the amount of lymphangiogenesis required to achieve physiological function, potentially leading to earlier functional recovery, though continued follow-up is necessary. The pedicled nature of this technique eliminates the need for microsurgical anastomosis, simplifying and shortening the procedure. Additionally, the proximal location of the pedicled flap may specifically offer advantages for patients with concomitant chronic venous disease, as flap lymphatics and lymph nodes drain efferent to the site of venous obstruction.