Plastic and reconstructive surgery最新文献

Background: Tissue expander (TE) infection is a critical postoperative complication in two-stage implant-based breast reconstruction (IBBR). We assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates.

Methods: We retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and IV antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement.

Results: Of 4,498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed higher body mass index, hypertension, radiation, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple sparing mastectomy were associated with increased hazard of TE infection. Patients with TE infection had a 54% reconstructive failure rate within 1 year; Cox modeling showed Black race and gram-negative cultures were associated with increased hazard of reconstructive failure within 1 year. Patients who underwent TE replacement with an implant had the most favorable success rate following infection.

Conclusion: Overall, 46% of patients admitted with a periprosthetic infection had successful salvage. Patients with TE infection should be started on IV antibiotics with a low threshold for operative intervention based on exam and culture data. While IR can guide operative intervention of periprosthetic infections, our practice has shifted away from IR drainage towards definitive operative management.

Background: Transfer of a healthy C7 spinal nerve is a tool for upper extremity reanimation in patients with severe brachial plexus injury (BPI). Its use remains controversial owing to concern for neurological injury to the donor arm. Utilizing wearable motion-sensor technology, we aimed to quantify donor arm morbidity after C7 spinal nerve harvest in patients with pan-BPI, reporting both the time and magnitude of donor arm movement in a real-world setting compared to healthy controls.

Methods: Seventeen patients who underwent contralateral C7 (CC7) transfer for traumatic pan-BPI at least 2 years prior were compared to 14 healthy controls. Each participant wore an accelerometer on both arms for 7 consecutive days. The vector time (VT), or time of movement measured in hours/day, and the vector magnitude (VM), or magnitude of arm movement measured as a single vector magnitude per second, were collected and compared between groups. The correlation between VT and VM and time from C7 spinal nerve harvest was also calculated.

Results: At mean 7.7 years after C7 spinal nerve harvest, there was no difference between donor and control arms for VT (5.76±1.55] vs 5.45±1.22 hours, P = 0.56) or VM (2242236±753853 vs 1919223±579723 activity counts, P = 0.20), regardless of donor arm dominance. The C7 harvest cohort used the injured arm 53% of the time and with 27% of the power of the donor arm.

Conclusions: There was no significant difference in time or magnitude of arm movement between donor arms and the arms of healthy controls.

Aim: This study aimed to validate the use of grayscale muscle ultrasound by measuring echo intensity to longitudinally evaluate functional muscle reinnervation in a rabbit peroneal nerve defect model.

Methods: Eighteen New Zealand White rabbits underwent a 30-mm peroneal nerve reconstruction with autografts or decellularized allografts. Ultrasound measurements of tibialis anterior muscles were performed before surgery and at 4, 8, 12, 16, 20, and 24 weeks postoperatively and included cross-sectional muscle area, mean gray value (MGV), and mean gray value normalized for area (MGVA). At 24 weeks, functional motor recovery was evaluated with isometric tetanic force (ITF) and compound muscle action potential (CMAP). MGVA data was compared with ITF and CMAP measurements by calculating the Spearman correlation coefficient.

Results: Muscle area (Left/Right Ratio (L/R)) of autografts was superior to allografts at 4, 12, 16, 20 and 24 weeks (p<0.03 for all comparisons). MGVs of the operated side were significantly higher for autografts at 4, 8, and 12 weeks and at 12, 16, 20, and 24 weeks for allografts (p<0.01 for all comparisons), compared to their unoperated sides. Similar patterns were seen in both groups for MGVA (operated versus control side). MGVA (L/R) demonstrated a strong correlation with ITF (L/R) for autografts (ρ = -0.7) and allografts (ρ = -0.87), but inconsistent with CMAPs (L/R).

Conclusion: Quantitative muscle ultrasound demonstrated a reliable, non-invasive tool for evaluating motor recovery in a rabbit peroneal nerve reconstruction model. Clinical translation could provide valuable insights into muscle health and structural changes following nerve reconstruction.

Background: We examined operative and pathologic findings of a large series of dermoid cysts at a high-volume pediatric hospital over 23 years.

Methods: A retrospective review was performed of all dermoid cysts excised from 2000 to 2023 at the Children's Hospital of Philadelphia. Lesions were classified by location. Depth was stratified into Type 1, superficial; Type 2, subperiosteal or containing a stalk to a cranial suture; Type 3, intraosseous or intracartilaginous; Type 4, intracranial extradural; and Type 5, intracranial intradural.

Results: Of 2,350 lesions, 2,237 (95.2%) were in the head and neck. Most common locations were lateral brow and orbit, 892 (38%); anterior neck, 303 (12.9%); and frontal, 253 (10.8%). Among the series, 67.9% were Type 1, 10.1% were Type 2, 16.5% were Type 3, 2.3% were Type 4, and 3.2% were Type 5. Older age at surgery correlated with depth among locations demonstrating intracranial extension (r=.061, p=.016). Anterior fontanelle (59.1%), nasal (16.2%), occipital (5.6%), and temporal (4.7%) lesions had the highest intracranial extension rates. Temporal (49.4%), frontal (32.8%), nasal (29.9%), and occipital (22.2%) lesions had higher rates of osseous/cartilaginous involvement. On histopathologic examination, 403 (17.1%) were ruptured. Ruptured lesions were associated with giant cell reaction (46.4 versus 5.7%, p<.001).

Conclusions: Anterior fontanelle, nasal, occipital, and temporal lesions are at higher risk of intracranial extension and may require preoperative imaging. Frontal and parietal lesions have a lower risk of intracranial involvement. Lateral brow and orbit, periauricular, and anterior neck lesions demonstrate a higher rate of osseous involvement without intracranial tracking.

Background: In 2021, a meta-analysis showed fat graft retention varied from 26 to 83%. In a retrospective study including patients with Parry-Romberg syndrome, the younger age group had higher satisfaction scores (3.8 vs. 3.0) after fat grafting. Cell-assisted lipotransfer (CAL) could be an alternative to overcome the instability of volume loss; however, no study investigated its effect on old recipients.

Methods: In an in vitro study, adipose-derived stromal cells (ASCs) from aged and young (52- and 8-weeks old) DsRed B6 mice were characterized by proliferation rates as percentages of Ki-67-positive cells. 68-week-old wild type B6 mice received 150 µL of green fluorescent protein fat (from 69-week-old B6 mice) mixed with saline, 3 x 105 aged or young DsRed ASCs (N, A, and Y groups, respectively) on the scalp (n = 6/group). After 8 weeks, graft volumes were evaluated using micro-computed tomography. Vessel densities were tracked by percentages of CD31 using immunofluorescence staining.

Results: Young ASCs showed higher proliferation than the aged (47.1% and 26.2%, respectively, p < 0.05). The Y group showed the highest graft retention (median: N = 41.0%, A = 52.2%, Y = 65.2%, p < 0.05) and percentage of blood vessels (median: N = 27.7%, A = 43.5%, Y = 54.7%, p < 0.05) among the three groups.

Conclusions: CAL is effective with old recipients; higher effect was observed by supplementation with younger ASCs due to higher angiogenesis stimulation. However, this is autologous grafting model, further validation of safety, toxicity, and allogenic grafting is required.

Clinical relevance statement: The results suggest that it is clinically possible to conduct CAL for old adults using autologous ASCs. However, further validation of using allogenic ASCs from young donors to improve graft retention in old adults is required.

Summary: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One downside is its risk of postsurgical herniation and bulging due to the opening of the rectus fascia and intramuscular dissection of the rectus abdominis muscle. Additionally this part of the surgery is very time consuming. While the superficial inferior epigastric artery perforator (SIEA) flap has been thoroughly described for total autologous breast reconstruction, the use of the superficial circumflex iliac artery perforator flap in this field is limited. This series introduces the use of an extended superficial circumflex iliac artery (SCIA) perforator flap nourished solely by perforators of the superficial branch of the SCIA- artery for total autologous breast reconstruction.Superficial preparation over the abdominal wall was performed without incising the rectus fascia, dissecting the superficial branch of the SCIA and its accompanying veins and the superficial inferior epigastric vein for additional venous drainage.Four patients underwent successful autologous breast reconstruction with this extended SCIP (superficial circumflex iliac artery perforator)-flap-variation. The term superficial circumflex iliac artery superficial branch perforator (SCISP) flap was introduced to standardize the surgical technique for using only perforators of the superficial branch of the SCIA as free flaps.The SCISP flap is safe and viable for total autologous breast reconstruction, particularly for women with small to medium sized breasts and with superficial dominance of the abdominal vascular system.

Background: Data exists to demonstrate that migraine surgery is cost-effective for the long-term treatment of headaches, but no data exists regarding its financial viability for healthcare institutions. The goals of the current study are to demonstrate that (1) migraine surgery is financially viable for an academic institution with a net-positive profitability and (2) migraine surgery is a sought-after therapy that can draw patients into the healthcare system.

Methods: A retrospective chart review of migraine and bilateral breast reduction (BBR) consults seen in clinic between 05/01/2011-05/30/2020 was conducted. Patient age, sex, payor information, and distance from the hospital was collected. Profit margin, percentage profit, collection percentage, and conversion rate to surgery from clinic was calculated.

Results: 407 new migraine consults and 119 new BBR consults were included from which, 150 underwent migraine surgeries and 117 underwent BBR respectively. Migraine surgery group came from a further distance for the initial consult (P-value<0.001) and for surgery (P-value<0.001). There were also more migraine surgery patients from out-of-state (P-value=0.012). Migraine clinic patients had a larger ratio of private insurers (P-value<0.001). Migraine surgery patients had a greater total charge (P-value<0.001), estimated reimbursement (P-value=0.001), and total cost (P-value<0.001).

Conclusions: This study provides evidence that migraine surgery is financially viable for hospitals and while performing similarly to bilateral breast reduction in profit margin, it brought in more patients from outside the catchment area of our institution. These findings may encourage hospitals to recruit migraine surgeons to improve care for this underserved patient population.

Background: Breast reconstruction following mastectomy for the treatment of breast cancer restores form and enhances patient satisfaction. The Affordable Care Act (ACA) of 2010 aimed to impact trends in breast reconstruction, but recent information regarding racial and ethnic disparities is lacking.

Methods: We analyzed National Surgical Quality Improvement Program (NSQIP) data spanning 2005-2022 to investigate the impact of ACA on racial and ethnic diversity in immediate breast reconstruction post-mastectomy. Patient demographics, including race and ethnicity, were considered. Statistical analyses included Pearson chi-square tests and multivariable logistic regressions to assess trends and disparities over time.

Results: In total, 224,506 patients met inclusion criteria. Analysis revealed that in the pre-ACA era, American Indian or Alaska Native, Asian, and Black or African American individuals underwent immediate breast reconstruction at lower rates compared to White patients (P < 0.001). Additionally, Hispanic patients were less likely to undergo breast reconstruction compared to non-Hispanic patients (28.0% vs 33.4%; P < 0.001). In the post-ACA period, this trend persisted with all racial groups undergoing immediate breast reconstruction at lower rates compared to White patients (P < 0.001). However, Hispanic patients were more likely to undergo immediate breast reconstruction compared to non-Hispanic patients (53.8% vs 47.9%, P < 0.001).

Conclusions: Despite legislative efforts and a steady increase in immediate breast reconstruction rates over the years, racial disparities in breast reconstruction rates persist, highlighting the need for ongoing monitoring and targeted interventions to ensure equitable reconstructive care for all patients.

Background: There is currently no consensus on the optimal treatment for Dupuytren contracture. Prior meta-analyses have been limited by suboptimal data synthesis methodologies. We conducted an updated evidence review comparing the effectiveness and safety of percutaneous needle fasciotomy (PNF), collagenase clostridium histolyticum (CCH), and limited fasciectomy (LF) using the GRADE approach.

Methods: CENTRAL, MEDLINE, and Embase were searched for randomized controlled trials comparing outcomes following PNF, CCH, and LF for Dupuytren contracture treatment. Outcomes of interest included residual contracture, recurrence rate, hand function, pain, global satisfaction, and adverse events. Time points included 3-months, 1-year, and 2-3 years.

Results: Seventeen publications (1,010 patients) were included. High to moderate certainty evidence showed no clinically important difference in long-term contracture reduction (PNF vs. LF (mean difference (MD): 7.6°; 95% CI: 1.8°-13.4°), CCH vs. LF (MD: 4.8°; 95% CI: -1.3°-10.9°)). Moderate certainty evidence indicated that LF provides the lowest risk of long-term recurrence (PNF vs. LF (relative risk (RR): 12.3; 95% CI: 1.6-92.4), CCH vs. LF (RR: 9.5; 95% CI 1.2-73.4)), LF has a higher risk of serious adverse events than PNF (RR: 0.5; 95% CI 0.3-0.9), and CCH has a higher risk of overall adverse events than PNF (RR: 4.8; 95% CI 2.9-7.0).

Conclusions: CCH, PNF, and LF are equally effective in long-term contracture reduction. However, LF yields more durable results at a higher risk of rare but serious adverse events. Current evidence suggests the use of PNF over CCH. However, ultimate treatment decisions should be tailored to individual patient preferences.

Background: Contralateral cervical seventh (cC7) nerve to C7 transfer has been proven effective for treating spastic upper limb. However, for those whose major impairment is not in the C7 area, cC7 nerve transfer to other nerves may achieve a better outcome. The aim of this study was to explore the optimal surgical approach for transferring cC7 to 1 or 2 nerves in a cadaveric study, and to evaluate possible applications for patients with hemiplegia.

Methods: Modified cC7 transfer to 1 (5 procedures) or 2 nonadjacent (3 procedures) nerve roots was proposed, and success rates of direct coaptation through 2 surgical approaches-the superficial surface of longus colli (sLC) and the deep surface of longus colli (dLC) approach-were compared. The length, diameter, and distance of relevant nerves were also measured in 25 cadavers.

Results: Compared with the sLC approach, the distance of the dLC approach was 1.1 ± 0.3 cm shorter. The success rates for the sLC and dLC approaches were as follows: cC7 to C5 surgery, 94%, and reached 98%; cC7 to C6 surgery, 54% and 96%; cC7 to C7 surgery, 42% and 94%; cC7 to C8 surgery, 34% and 94%; cC7 to T1 surgery, 24% and 62%; cC7 to C5C7 surgery, 74% and 98%; cC7 to C6C8 surgery, 54% and 98%; and cC7 to C7T1 surgery, 42% and 88%.

Conclusions: The dLC approach greatly improved the direct coaptation rate for cC7 nerve transfer. The modified cC7 nerve transfer procedures are technically feasible for further application in clinic.