Plastic and reconstructive surgery最新文献

Background: For women in the United States desiring implant-based breast reconstruction, the maximum volume of commercially available silicone breast implants has, to date, been 800cc. We evaluated the safety of MENTOR® larger-size MemoryGel® Ultra-High Profile breast implants (≥930cc) in women undergoing postmastectomy breast reconstruction.

Methods: This 10-year, multicenter, open-label, prospective, investigational study assessed the safety and effectiveness of larger-volume implants in women undergoing postmastectomy 2-stage primary or revision reconstruction. Three-year Kaplan-Meier curves and multivariable Cox regression analyzed the association between patient and treatment characteristics and surgical outcomes. Breast-Q was used to assess effectiveness at 3 years.

Results: Four hundred women were enrolled (225 primary, 175 revision reconstruction). Mean body mass index (BMI) was 35.8 kg/m2; 81% had a BMI ≥30 kg/m2. At 3 years, the cumulative incidence of postoperative complications (excluding rupture) was 63.0% (95% confidence interval [CI], 58.1-67.9). The reoperation rate was 24.5% (95% CI, 20.4-29.1), and the explantation rate was 15.8% (95% CI, 23.5-19.9). Independent predictors of complications included radiation and a history of smoking. There were no significant associations between postoperative complications and implant volume ≥1135cc or <1135cc. Breast-Q scores at Year 3 showed significant improvements from baseline in satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being (all P<0.0001). The mean score for satisfaction with outcome was 79.9.

Conclusions: These 3-year results demonstrate that larger-volume silicone breast implants represent a safe and effective option for patients with larger breasts who are requesting postmastectomy implant-based reconstruction.ClinicalTrials.gov Identifier: NCT02724371.

Background: The posterior radial collateral artery perforator free flap (PRCA flap) is a modification of the lateral arm flap that provides pliable tissue, color match, and primary donor-site closure. However, evidence on pedicle length remains limited, particularly in Asian populations. This study evaluated pedicle length stability and its correlation with body size.

Methods: A retrospective review was performed of 100 consecutive PRCA flap reconstructions for head and neck defects at Taipei Medical University Hospital between 2016 and 2024. Demographics, defect sites, flap dimensions, pedicle length, perforator location, recipient vessels, ischemia time, and donor-site closure were analyzed. True pedicle length was defined as the vascular segment from the selected perforator to the proximal transection point, excluding segments with only soft tissue. Correlations with height, arm length, and BMI were tested using regression.

Results: The mean age was 55.5 years (range, 27-84), and 85% were male. Malignancies accounted for 80% of defects, most commonly buccal mucosa (40%) and tongue (36%). The mean skin paddle measured 7.4 × 4.3 cm, and mean pedicle length was 9.7 ± 1.4 cm (range, 6-14 cm). The distal perforator was 4.7 ± 1.5 cm proximal to the lateral epicondyle. Pedicle length showed no correlation with height (R² = 0.022), arm length (R² = 0.004), or BMI (R² = 0.013). All donor sites were closed primarily.

Conclusions: The PRCA flap provides a reliable pedicle length independent of patient height and habitus, supporting its role as a safe, versatile option for small- to medium-sized head and neck reconstructions, particularly in Asian populations.

Introduction: The depressor-labii-inferioris (DLI), depressor-anguli-oris (DAO), mentalis, and platysma muscles control lower lip position-essential for smiling and oral function-and are at risk during facial reconstructive and aesthetic procedures. Prior anatomical studies, lacking functional analysis, suggested the marginal mandibular nerve (MMn) significantly contributes to mid-lower lip depression through DLI innervation. This study systematically assessed the functional anatomy and innervation of these muscles and evaluated whether MMn injury worsens lower lip position.

Methods: A retrospective cohort study of prospectively collected data included adult synkinesis patients undergoing selective neurectomies and myectomies with unilateral facial nerve mapping. Intraoperatively, facial nerve branches were stimulated and categorized by muscle activation patterns. Additional sub-analysis evaluated lower lip position changes using pre- and postoperative photographs in patients who underwent MMn neurectomy without platysma myectomy.

Results: Of 82 patients, 45 met inclusion (mean age: 51.5; 87% female). An average of 11.3 nerve branches were mapped per patient: zygomatic (2.80), buccal (4.36), MMn (1.16), and cervical (3.02). DAO and mentalis demonstrated mixed innervation patterns. DLI and platysma were predominantly cervical; 95.5% of DLI branches were cervical with 68.8% being pure DLI branches. In the sub-analysis (n=24), MMn neurectomy did not worsen lower lip position.

Conclusions: The DAO, mentalis, and platysma muscles are poly-innervated by buccal, MM, and cervical branches, while the DLI is mostly mono-innervated by cervical branches. Isolated MMn injury rarely worsens lower lip position, while injury to cervical branches to the DLI causes abnormal lower lip elevation and can be avoided by more caudal platysma myotomy.

Purpose: Massive weight loss after bariatric surgery is often associated with alterations in breast morphology, including ptosis, excess skin, poor tissue elasticity, and altered nipple position, which frequently motivate requests for breast surgery. However, data on implant-based augmentation after massive weight loss are sparse and often limited to small series. This study aimed to compare surgical techniques and implant selection in post-bariatric patients versus non-bariatric women undergoing primary augmentation.

Methods: We conducted a national, population-based case-control study within the Breast Reconstruction After Bariatric Surgery protocol (NCT07059104). Patients occurring in both the Scandinavian Obesity Surgery Registry and the Swedish Breast Implant Registry were identified. A non-bariatric control group having breast augmentation was created.

Results: A total of 817 post-bariatric patients (1634 breasts) and 3512 controls (7023 breasts) were analysed. Surgery occurred a median of 3.4 years after bariatric surgery. Post-bariatric patients reported greater dissatisfaction with breast volume. They more often received larger implants, round shapes, and micro- or macro-textured or polyurethane surfaces. Dual-plane or submuscular placement was predominant in both groups, whereas subfascial and subglandular placements were less common in post-bariatric patients. Augmentation mastopexy was more frequent, while the use of mesh/ADM and lipofilling remained rare. Postoperative antibiotics were prescribed more often to post-bariatric patients.

Conclusion: Breast augmentation after massive weight loss differs from standard practice, with larger and more textured implants and a higher frequency of mastopexies, highlighting surgical adaptation to complex anatomy.

Background: Discrepancies between assigned and actual operative durations may distort time-based valuation of surgical procedures. This study evaluated the impact of operative time source on wRVU per minute and reimbursement per minute across commonly reimbursed reconstructive plastic surgery operations.

Methods: Using 2023 National Surgical Quality Improvement Program (NSQIP) data, we compared actual operative times for 11 commonly reimbursed plastic surgery procedures to CMS-assigned times from the Physician Fee Schedule. Each CPT (15830, 19316, 19318, 19325, 19340, 19342, 19357, 19364, 19370, 19371, 19380) was linked to its CMS-assigned wRVU. wRVU per minute and reimbursement per minute were calculated using both NSQIP-observed and CMS-assigned operative times. Statistical analyses included Wilcoxon signed-rank tests, Kruskal-Wallis tests, Spearman correlations, and multivariable linear regression.

Results: Among 6,537 single-CPT cases, CMS underestimated operative time in 5 of 11 procedures. The largest discrepancies were observed in immediate implant insertion (+93.5 min), free flap breast reconstruction (+60.5 min), and breast augmentation (+18.5 min), resulting in reduced wRVU/min and $/min. Time discrepancy correlated strongly with reduced wRVU/min (ρ=-0.84). NSQIP-modeled reimbursement showed 2,637 single-CPT cases (40.3%) as underpaid, totaling $751,149.18. Among 15,570 multi-CPT cases, 5,099 (32.7%) were under-reimbursed, with a cumulative modeled underpayment of $2,002,956.29.

Conclusions: CMS operative times frequently underestimated the duration of plastic surgery procedures. Time discrepancies were associated with substantial reductions in wRVU/min and $/min, particularly for complex or implant-based operations. These findings suggest that current CMS time assignments do not adequately capture operative complexity and may contribute to systematic underpayment in reconstructive surgery.

We describe a novel technique for a single stage nailbed preserving debulking procedure for macrodactyly used in our unit. This simple technique preserves the perfusion and venous drainage of the nailbed complex by a subperiosteal dissection and the use of a dermal bridge by de-epithelialisation of the proximal area and subsequently folding the nailbed flap back onto itself in a pleated fashion. Four toes in three patients were treated with this technique and all achieved a shorter and less bulky appearance with nail preservation at a 2 year follow up. We believe that the single stage pleated nailbed flap is a simple and robust method of nail complex preservation in cases of macrodactyly debulking, which gives good cosmetic results and high patient satisfaction.

Introduction: Ventral hernia repair in oncologic patients is challenging due to poor tissue quality, immunosuppression, malnutrition, and prior operations. Limited data exists comparing the outcomes of biosynthetic (Poly-4-hydroxybutyrate) and synthetic mesh in this population. This study aims to assess the outcomes in patients who undergo hernia repair using one of two mesh types.

Methods: Patients undergoing ventral hernia repair by the Plastic and Reconstructive Surgery service and general surgery after oncologic resection from 2010 to 2023 were included, with patient records reviewed and cases identified in a prospectively maintained database by the Plastic and Reconstructive Service. Repairs were done in a retrorectus, underlay, or onlay fashion with either biosynthetic or synthetic mesh. Primary endpoints included complication rates (hematoma, infection/cellulitis, wound dehiscence, abscess, seroma) and hernia recurrence.

Results: 207 patients underwent repair (102 biosynthetic, 105 synthetic) and were included. Baseline demographics were similar between groups. No significant difference was observed in complication rates (biosynthetic: 24%, synthetic: 18%; p=0.3). Hernia recurrence was noted in 8.8% of biosynthetic and 6.7% of synthetic mesh cases (p>0.6). Subgroup analysis of wound classes II-IV showed consistent results. Up to two years postoperatively, synthetic mesh did not significantly reduce hernia recurrence risk compared to biosynthetic mesh (Subdistribution Hazard Ratio (sHR): 0.66; 95% CI, 0.27-1.59; p=0.4). Bilateral external abdominal oblique release (sHR: 0.31; 95% CI, 0.11-0.87, p=0.026) and retromuscular mesh placement (sHR: 0.08; 95% CI, 0.02, 0.35, p<0.001) exhibited a protective role.

Conclusion: Biosynthetic mesh can be considered a reasonable alternative to synthetic mesh in this high-risk population.

Background: Deep inferior epigastric perforator (DIEP) flaps provide a durable, autologous breast reconstruction option, but can lead to post-operative abdominal bulges and hernias. There is no current standardization in practice for fascial closure or mesh placement. Bioprosthetic poly-4-hydroxybutyrate (P4HB) mesh allows for temporary abdominal support without the long-term risks of permanent mesh.

Methods: A retrospective chart review was conducted of a single surgeon's patients who underwent DIEP flaps from 2020-2024. During the study period the primary surgeon began using retrorectus bioprosthetic mesh prior to fascial closure. Abdominal bulge was a clinical diagnosis made by the attending surgeon, and any patient with concern for a hernia received post-operative imaging. Analysis was conducted with R and included Fisher's exact test, Shapiro-Wilk's test, Mann-Whitney U test, and t-tests.

Results: This study included 118 patients, 59 with mesh and 59 without mesh, with similar baseline patient demographics. There was a 5.1% bulge rate in the group with mesh compared to 18.6% in those without mesh (p=0.04). There was no significant difference in hernia rates, with the base rate remaining low for these patients (p=1.0). There were no statistically significant differences in the rates of seroma or infection between the groups (p=1.0).

Conclusions: There was a three-fold decrease in the rate of abdominal bulge after DIEP flap surgery with retrorectus P4HB mesh. True hernia risk remains low in these patients. Retrorectus mesh placement is a straightforward and quick addition to DIEP flap harvest and may help to reduce the abdominal morbidity of this surgery.

Background: Pressure ulcers impose a significant healthcare burden on both the individual and societal level. The gold standard for treatment is flap reconstruction, which historically has high complication and recurrence rates. The aim of our study was to determine factors associated with complications and recurrence in our large patient population.

Methods: Retrospective chart review of patients who underwent muscle, myocutaneous, or fasciocutaneous flaps from January 2010 to July 2022 for pressure ulcer reconstruction at our tertiary academic institution. Demographic and outcome data were analyzed to determine factors associated with complications and recurrence.

Results: A total of 326 patients met inclusion criteria, with 418 flaps performed. Recurrence occurred in 98 flaps (23.4%), and the complication rate was 48.3%. Factors significantly associated with recurrence (p < 0.05) included elevated preoperative CRP, current tobacco use, post-operative infection, and non-compliance. Factors associated with lower recurrence included higher preoperative prealbumin (p = 0.01), preoperative IV antibiotics (p < 0.0001), and autonomic dysfunction (p = 0.04). Preoperative osteomyelitis, present in 70.2% of cases, was not linked to recurrence but was associated with higher complication rates (p = 0.01). A pre-operative optimization algorithm was created. Patients who followed it had lower recurrence (17.3%) and complication rates (46.4%) compared to those who did not (24.6% and 48.7%, respectively).

Conclusion: Modifiable pre- and post-operative factors influence pressure ulcer recurrence following flap reconstruction. Optimizing nutrition, infection control, smoking cessation, and patient compliance may improve outcomes.

Introduction: The Lancet Diabetes and Endocrinology Commission proposed a new definition of obesity that de-emphasizes body mass index (BMI) in favor of adiposity-related comorbidities. Our study evaluates the relevance of this paradigm shift to Plastic and Reconstructive Surgery (PRS) by analyzing the effects of BMI and adiposity-related comorbidities on 30-day complication rates.

Methods: The TriNetX health database was queried for patients undergoing PRS procedures. Patients were stratified by BMI categories and presence/absence of adiposity-related comorbidities. Cox regression analyses determined hazard ratios (HR) for 30-day complications with subset analyses performed by procedural complexity.

Results: Among 957,985 patients, those with BMIs 25-39.9 and comorbidities (HR 1.05, p<0.001) or BMIs ≥40 (HR 1.40, p<0.0001) had significantly higher complication risks compared to normal-weight patients. Without comorbidities, patients with BMIs 25-29.9 had a lower risk (HR 0.83, p<0.0001), while those with BMIs 30-34.9 showed similar risk (HR 0.99, p=0.62) to normal-weight patients. An inflection point occurred at BMIs above 35, where complication risk increased even without comorbidities. Subset analysis revealed that BMI effects were most pronounced in body contouring procedures, with patients having BMIs ≥25 showing significantly increased risk, regardless of comorbidity status.

Conclusions: These findings partially support this new definition in the context of PRS. For patients with BMIs of 25-34.9 without comorbidities, weight loss may not change surgical risk. Comprehensive assessment of comorbidities should be considered for patients with BMIs 25-34.9, while weight loss or other risk mitigation strategies such as GLP-1 agonists may be recommended for patients with BMIs ≥35.