Plastic and reconstructive surgery最新文献

Background: The spinal accessory nerve is occasionally injured during brachial plexus injuries, potentially limiting its use as a donor motor nerve for reconstructive surgery. Assessing spinal accessory nerve function preoperatively is essential to optimize outcomes in brachial plexus reconstruction. The authors examined the demographics of spinal accessory nerve injury, focusing on its prevalence, predisposing factors, and potential for spontaneous recovery in patients with brachial plexus injuries.

Methods: A total of 170 patients were included in this study. At the first visit, the spinal accessory nerve function was assessed by measuring the compound muscle action potential of the upper trapezius muscle. The function of the nerve was classified as follows: no injury (amplitude of the potential ≥50% compared with the unaffected side), partial injury (amplitude <50%), and severe injury (absence of the potential). For the evaluation of spontaneous recovery, patients with partial and severe injuries underwent further assessment at 1 year after the injury and at the final follow-up.

Results: The authors found the associated spinal accessory nerve injury in 30 patients (17.6%) (partial, 17; severe, 13). Spinal accessory injury occurred in 13 of 39 patients with phrenic nerve palsy (33.3%). Phrenic nerve palsy may serve as a predisposing factor for this injury. In 18 patients followed up for more than 1 year, 15 (83.3%) showed good spontaneous recovery.

Conclusions: Spinal accessory nerve injury occurred in approximately 18% of patients with brachial plexus injuries. Most cases of spinal accessory nerve injury associated with brachial plexus injury have a potential for good spontaneous recovery.

Summary: Preservation rhinoplasty emphasizes maintaining ligament integrity for stable and natural surgical outcomes. However, its principles have not yet been applied to primary or secondary cleft nasal deformities. In their experience using a modified Tajima (reverse U) incision for cleft nasal reconstruction, the authors have previously reported unique kinking distortions in the cleft-side lower lateral cartilage and distinct soft-tissue attachments in abnormal relationship with the dome and crural regions. This raises questions about the role of the Pitanguy ligament-a key structure for nasal stability-in these deformities. During primary lip and nose repair on 6 infants with cleft lip and palate (3 unilateral and 3 bilateral), the authors adapted preservation rhinoplasty principles by releasing and repositioning the Pitanguy ligament. This approach alleviated tension on the nasal tip, expanded the skin envelope, and facilitated precise midline alignment of the lower lateral cartilages through controlled reconstruction of the intercrural and interdomal ligaments. The authors' findings suggest that preservation rhinoplasty principles, particularly ligament release and reconstruction, may offer functional and aesthetic improvements in cleft nasal surgery. This approach could represent a promising direction for primary and secondary cleft rhinoplasty, focusing on ligament management to achieve balanced and lasting outcomes. Further studies are needed to validate these findings and establish normative references for cleft anatomy.

Background: Radiation therapy (RT) significantly increases the risk of capsular contracture after implant-based breast reconstruction. However, the relationship between anatomic plane placement (eg, submuscular or prepectoral) and the development of capsular contracture remains unclear. This study compared the risk of RT-induced capsular contracture in patients who underwent 2-stage prepectoral versus submuscular implant reconstruction.

Methods: The authors conducted a retrospective analysis of patients who underwent 2-stage implant reconstruction with radiation to the tissue expander between 2010 and 2024 at a single institution. Capsular contracture was evaluated and classified by the Baker scale. Patients with documented Baker II, III, or IV capsules were considered to have developed capsular contracture. Cox proportional hazards models were used to identify predictors of contracture, and Kaplan-Meier curves were used to estimate the cumulative incidence in prepectoral versus submuscular reconstruction.

Results: A total of 585 patients were included; 116 underwent prepectoral and 469 underwent submuscular implant placement. Capsular contracture occurred in 62% of submuscular and 18% of prepectoral cases ( P < 0.001). The estimated 48-month cumulative incidence of capsular contracture was 61% (95% CI, 56% to 65%) for submuscular and 35% (95% CI, 19% to 47%) for prepectoral reconstruction ( P < 0.001). Submuscular implant placement was associated with a significantly higher risk of developing capsular contracture over time than prepectoral reconstruction (hazard ratio, 3.00 [95% CI, 1.88 to 4.79]; P < 0.001).

Conclusions: In the setting of RT, submuscular implant placement is associated with a significantly higher risk of capsular contracture compared with prepectoral placement. These findings emphasize the need for thorough patient counseling regarding the risks of capsular contracture and the importance of individualized reconstructive planning to optimize outcomes in patients undergoing radiation treatment.

Background: The adoption of glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide, has significantly improved obesity and type 2 diabetes management. However, their unintended side effects, particularly facial volume loss, termed "Ozempic face," have disrupted aesthetic medicine. This intersection between metabolic health and aesthetics raises ethical dilemmas and growing dependency on corrective interventions such as dermal fillers.

Methods: A mixed-methods approach was used, incorporating content analysis, social media sentiment analysis, and social network modeling. Data were collected from 15 peer-reviewed studies, clinical reports, and 3.79 million social media posts across global regions. Sentiment analysis identified public perceptions, whereas network analysis examined influencer dominance in promoting aesthetic solutions.

Results: Findings revealed a 40% increase in filler consultations attributed to GLP-1-related aesthetic concerns. Sentiment analysis showed that 72% of high-engagement content was driven by influencers normalizing fillers as necessary adjuncts to GLP-1 therapies. Ethical concerns were prominent, particularly in regions such as Asia and South America, where commercial narratives dominate. In contrast, North America and Europe demonstrated a more balanced approach, prioritizing informed patient care under regulatory frameworks.

Conclusions: GLP-1 therapies represent a transformative shift in metabolic care but introduce significant aesthetic, ethical, and psychological challenges. Social media amplifies commercial influences, often at the cost of evidence-based practice. Regulatory reforms, longitudinal studies, and enhanced patient education are critical to navigating this evolving landscape and ensuring patient well-being.

Background: The resource-based relative value scale and its working relative value units (wRVUs) is a common model for surgeon compensation. The number of wRVUs per Current Procedural Terminology (CPT) code has been negotiated considering the degree of time, skill, and labor associated with each procedure, across all operative stages. The authors aimed to quantify and elucidate the rate of wRVUs per minute of elective compared with traumatic hand surgical procedures.

Methods: The authors included elective and traumatic hand surgery cases from a single academic institution between October 1, 2015, and July 1, 2023. Average operative duration and wRVU/min rates were calculated for CPT codes with at least 10 occurrences. Centers for Medicare & Medicaid Services data were used to estimate expected values for the same procedures.

Results: CPT 29848 (endoscopic carpal tunnel release) had the greatest earning rate, at 0.80 wRVUs/min. CPT 26350 (flexor tendon repair, not in zone 2) had the lowest rate, at 0.09 wRVUs/min. Elective procedures had an average wRVU/min rate that was more than twice the rate for traumatic procedures (0.34 versus 0.15 wRVU/min; P < 0.001). Traumatic cases had a negative correlation between wRVU/min rate and intraoperative time (r = -0.56; P = 0.04).

Conclusions: Despite the complexity and urgency of trauma procedures, the authors found a significantly lower average wRVU/min rate for traumatic compared with elective hand surgical procedures. These results highlight the need for discussion of RVU valuation of traumatic hand surgical procedures.

Background: Oral propranolol is the first-line treatment for problematic infantile hemangiomas (IHs) requiring systematic therapy. Several retrospective studies have reported the successful treatment of facial IHs with propranolol. In this study, the authors conducted a prospective trial to evaluate the long-term outcomes of oral propranolol use in patients with facial IHs.

Methods: The primary outcome was the clinical response 4 years after treatment.

Results: A total of 272 patients were analyzed, including 38 patients (14.0%) with ulcerated IHs. Four years after treatment, propranolol treatment had resulted in no/minimal sequelae in 232 patients (85.3%). A total of 265 patients (97.4%) reported a durable response to propranolol therapy. Major rebound occurred in 16.9% of patients after propranolol discontinuation. Additional surgery and laser treatment were required in 8.1% and 8.8% of patients, respectively. Logistic regression analyses revealed that age 3 months or older (95% CI, 1.488 to 31.023; P = 0.013), nasal IH (95% CI, 2.143 to 97.571; P = 0.006), and hemangioma ulceration (95% CI, 2.673 to 49.034; P = 0.001) were independent factors predictive of long-term severe/significant sequelae. Segmental subtype (95% CI, 2.081 to 45.597; P = 0.004), mixed IH (95% CI, 3.249 to 26.841; P < 0.001), and lip IH (95% CI, 2.224 to 92.278; P = 0.005) were independent risk factors for major rebound.

Conclusions: In this large cohort of patients with facial IHs, propranolol treatment was effective and induced no/minimal sequelae at 4 years after treatment. However, long-term severe/significant sequelae and major rebound after propranolol treatment remain challenges.

Background: Alveolar ridge defects associated with cleft lip and palate are typically repaired using alveolar bone grafting (ABG), with autologous grafting as the standard despite donor-site morbidity. This study investigated outcomes of using hydroxyapatite/ß-tricalcium phosphate (HA/TCP) as a synthetic graft alternative.

Methods: A retrospective cohort study identified 118 patients who underwent ABG by means of CPT codes and were divided into 3 groups: autologous iliac crest bone graft (ICBG) ( n = 37), ICBG plus recombinant human bone morphogenetic protein-2 (rhBMP-2) ( n = 65), and 15% HA/TCP plus rhBMP-2 ( n = 16). Primary outcomes included need for regrafting and percentage graft take, assessed by means of cone beam computed tomographic imaging. Secondary outcomes included complication rates (swelling, wound dehiscence, surgical-site infection) and perioperative data (surgery length, hospital stay).

Results: Patients who received HA/TCP plus rhBMP-2 experienced similar rates of need for regrafting to the other groups. The median percentage graft take was higher for HA/TCP plus rhBMP-2 (68.0%; interquartile range [IQR], 45.9% to 93.1%) compared with ICBG (25.1%; IQR, 5.2% to 43.5%; Z = 3.16; P = 0.002) and ICBG plus rhBMP-2 (44.2%; IQR, 24.5% to 63.1%; Z = 2.19; P = 0.028). Complication rates were similar across groups (dehiscence, P = 0.319; surgical-site infection, P = 0.357), except for a higher rate of postsurgical facial swelling for HA/TCP plus rhBMP-2 compared with ICBG (OR, 6.8; 95% CI, 1.44 to 32.00; P = 0.0157).

Conclusion: HA/TCP plus rhBMP-2 is a viable alternative to ABG, showing comparable success to ICBG and ICBG plus rhBMP-2, with superior percentage graft take and no increased complication risk, aside from increased postsurgical facial swelling compared with ICBG.

Background: Cost-utility analyses require utilities data, which are often unavailable in hand surgery, where functional scores are more commonly used. This study aims to develop predictive models to accurately map 2 dominant legacy questionnaires for the hand specialty, Michigan Hand Outcomes Questionnaire (MHQ) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores onto the 5-level EuroQol-5 Dimension (EQ-5D). This will facilitate more economic evaluations of the growing number of hand procedures.

Methods: Data were collected prospectively from 354 patients diagnosed with various hand conditions at the University of Michigan Hospital. Participants completed the MHQ, DASH, and EQ-5D surveys. We evaluated 6 statistical models to determine the best fit for mapping MHQ and DASH onto EQ-5D. Model performance was assessed using mean absolute error (MAE), root mean squared error (RMSE), R², and proportion of predictions within 0.1 and 1 SD of true EQ-5D values.

Results: The logarithmic response mapping model was the best fit for mapping MHQ to EQ-5D (MAE, 0.1119; RMSE, 0.1584; R² , 0.445), whereas the ordinary least squares model performed best for DASH (MAE, 0.0934; RMSE, 0.1347; R² , 0.601). Both models showed strong predictive accuracy, with 58% (MHQ) and 68% (DASH) of predictions within 0.1 of observed EQ-5D scores, and over 85% within 1 SD.

Conclusions: Response mapping and ordinary least square models are reliable methods to map MHQ and DASH onto EQ-5D. These mapping algorithms offer a valuable alternative for obtaining utilities in the absence of direct data.