Plastic and reconstructive surgery最新文献

Background: Overhanging pannus may be detrimental to ambulation, urination, sexual function, and social well-being. Massive weight loss patients often have high residual body mass index (BMI) and comorbidities presenting a unique challenge in panniculectomy patient selection. This study aims to better characterize the role of BMI in postoperative complications following panniculectomy.

Methods: A meta-analysis attempted to assess the impact of BMI on complications following panniculectomy. Cochrane Q and I2 test statistics measured study heterogeneity, with subsequent random effects meta-regression investigating these results. After this, all panniculectomy patients in the National Surgical Quality Improvement Program database in the years 2007 to 2019 were analyzed. Univariate and multivariable tests assessed the relative role of BMI on 30-day postoperative complications.

Results: Thirty-four studies satisfied inclusion criteria, revealing very high heterogeneity (Cochrane Q = 2453.3; I2 = 99.1%), precluding further meta-analysis results. Receiver operating characteristic curves demonstrated BMI was a significant predictor of both all causes (area under the curve, 0.64; 95% CI, 0.62 to 0.66) and wound complications (area under the curve, 0.66; 95% CI, 0.63 to 0.69). BMI remained significant following multivariable regression analyses. Restricted cubic spines demonstrated marginal increases in complication incidence above 33.2 and 35 kg/m 2 for all-cause and wound complications, respectively.

Conclusions: Reported literature regarding postoperative complications in panniculectomy patients is highly heterogeneous and may limit evidence-based care. Complication incidence positively correlated with BMI, although the receiver operating characteristic curve demonstrated its limitations as the sole predictive variable. Furthermore, restricted cubic splines demonstrated diminishing marginal predictive capacity of BMI for incremental increases in BMIs above 33.2 to 35 kg/m 2 . These findings support a reevaluation of the role of BMI cutoffs in panniculectomy patient selection.

Background: Autologous breast reconstruction confers favorable patient reports of satisfaction and quality of life compared with implant-based reconstruction over a lifetime. The latissimus dorsi with immediate fat transfer (LIFT) is an alternative approach to abdominally based free flaps (Ab-FF), which expands fully autologous reconstruction to nonmicrosurgeons. This study compared the 2 procedures concerning their clinical and patient-reported outcomes 1 year postoperatively.

Methods: The authors conducted a retrospective review of LIFTs and Ab-FFs performed between March of 2017 and August of 2022. The primary outcomes were postoperative complications, reoperations, and longitudinal BREAST-Q scores. BREAST-Q modules included Satisfaction with Breasts, Satisfaction with Abdomen, Satisfaction with Back, Psychosocial Well-being, Physical Well-being: Chest, Physical Well-being: Abdomen, Physical Well-being: Back, and Sexual Well-being.

Results: Of the 281 included patients (408 breasts), 211 received Ab-FF and 70 received LIFT. One-year follow-up (median [interquartile range], 12 [12] months) demonstrated that Ab-FF independently predicted dehiscence, reoperation procedures, and revisional surgery. LIFT independently increased the odds of seroma. Obesity predicted dehiscence, and bilateral reconstructions predicted revisional fat grafting. BREAST-Q scores fluctuated over time but were similar across all measured domains by 1 year postoperatively.

Conclusions: Although Ab-FF is the standard approach for fully autologous reconstruction, LIFT procedures may be associated with a less complicated postoperative course while eliciting similar patient-reported outcomes. LIFT may be preferred to limit postoperative complications, particularly in patients with obesity. LIFT can be used by plastic surgeons who are not trained in microsurgical procedures or do not have an environment that fosters Ab-FF.

Clinical question/level of evidence: Therapeutic, III.

Background: Patients with micrognathia undergoing mandibular distraction osteogenesis (MDO) for functional and aesthetic improvement are at significant risk for dental complications. The authors investigated the association of 2 osteotomy patterns-oblique and inverted-L-with risk to developing dentition.

Methods: A senior orthodontist (H.D.N.) performed a retrospective review of dental radiographs of patients undergoing MDO with confirmed oblique or inverted-L osteotomies between 2012 and 2022. Images were assessed for evidence of missing, damaged, or displaced teeth, and proportion of affected hemimandibles by injury type and median number of affected teeth per hemimandible were compared between groups using appropriate statistical methodology.

Results: Analysis included 44 patients (23 oblique, 21 inverted-L) and 85 hemimandibles (45 oblique, 40 inverted-L). Mean age at surgery was 3.1 ± 4.6 years, and mean time to imaging was 4.9 ± 4.1 years; there was no difference between groups ( P = 0.23, P = 0.34, respectively). Oblique osteotomy was associated with greater odds of missing teeth (odds ratio [OR], 13.3, P < 0.001), damaged teeth (OR, 3.2; P = 0.02), and any dental injury (OR, 39.9; P < 0.001) compared with inverted-L, as well as greater number of missing teeth (β = 0.6; P < 0.01), damaged teeth (β = 0.3; P = 0.02), and total number of affected teeth (β = 0.9; P < 0.001). There was no difference in incidence ( P = 0.5) or number ( P = 0.4) of displaced teeth between groups.

Conclusions: Inverted-L osteotomies were associated with fewer dental complications compared with oblique osteotomy at all ages studied. Although longer-term follow-up and prospective data are needed before definitive recommendations can be made, these data are helpful to surgeons as they plan MDO.

Clinical question/level of evidence: Therapeutic, III.

Background: Radiographic severity of metopic synostosis has been suggested as a predictor of long-term neurocognitive outcomes, and artificial intelligence (AI) has recently been used to quantify severity. Age at surgery is predictive of long-term neurocognition in sagittal synostosis but has not been adequately explored in metopic synostosis.

Methods: Children ages 6 to 18 years with corrected metopic synostosis underwent testing of intelligence quotient, academic achievement, and visuomotor integration (VMI). Various manual measurements and AI-derived severity scores were determined. Scans were categorized as moderate or severe for head-to-head comparisons and multivariable linear regressions were used to assess the relationship of age at surgery and severity with neurocognitive outcomes.

Results: A total of 41 patients with average age at testing of 10.8 ± 3.4 years were included. A total of 18 patients were in the severe group and 23 patients were in the moderate group, with average ages at surgery of 6.6 ± 2.7 and 10.6 ± 8.4 months, respectively ( P = 0.062). Greater AI-derived severity was significantly associated with lower reading comprehension ( P = 0.040 and 0.018) and reading composite scores ( P = 0.024 and P = 0.008). Older age at surgery was significantly associated with lower VMI scores ( P values ranging from 0.017 to 0.045) and reading composite scores ( P = 0.047 and 0.019).

Conclusions: This study suggests an association between greater AI-derived radiographic severity and lower reading ability in corrected metopic synostosis. Older age at surgery was independently associated with lower reading ability and VMI. Surgical correction may mitigate neurodevelopmental differences based on severity that have been observed preoperatively.

Clinical question/level of evidence: Risk, II.

Background: Follicular vitiligo is a distinct subtype of vitiligo characterized by the selective destruction of the follicular melanocytic reservoir. Treatment of follicular vitiligo-associated leukotrichia has always been a clinical challenge.

Methods: Twenty participants (mean age, 29 years) with stable follicular vitiligo were recruited between 2020 and 2021 for 2-stage surgery. In stage 1, an incision around the vitiligo lesion was performed to subcutaneously dissect and scrape the leukotrichia. In stage 2, healthy follicles obtained from the occipital donor site were transplanted into the vitiligo area. Follow-up examinations were conducted for 1 year postoperatively using a camera and dermatoscope to observe the growth rate, color, and surviving number of the transplanted hairs. Patient satisfaction was recorded to evaluate the potential surgical improvement.

Results: The transplanted hair grew with natural texture, as expected. The average survival rate of the transplanted hair follicles was 93.8%. No recurrence of leukotrichia was observed in the recipient area. No complications were observed, and the postoperative scars in the recipient area were entirely covered by black hair. All patients were satisfied with their resulting appearance.

Conclusion: Minimally invasive removal of leukotrichia combined with hair transplantation might be an appropriate surgical option for stable follicular vitiligo to create natural and stable pigmented hair.

Clinical question/level of evidence: Therapeutic, IV.

Background: Although the efficacy of botulinum toxin type A (BoNTA) has been shown to vary depending on injection layer, reconstitution volume, and BoNTA formulation, the effect of injection pattern has rarely been mentioned. The authors compared the therapeutic effects in patients treated with BoNTA with retrograde linear and traditional spot injection techniques.

Methods: Twenty-eight participants were enrolled in a split-face, patient-blinded randomized clinical trial. Each patient received BoNTA injected with linear injection technique on one side and with spot injection technique on the other side. Outcomes included wrinkle improvement rates (WIRs) of the 2 injection techniques determined by wrinkle scores derived from an Antera 3-dimensional camera, muscle activity assessed by ultrasound, and patient-reported pain rating on a numeric rating scale.

Results: All participants completed the study. For forehead wrinkles, WIR on the linear side was significantly larger than that on the spot side at 1 week and 1 month ( P < 0.02). For glabellar wrinkles, WIR on the linear injection side was significantly larger than that on the spot side at 1 week ( P = 0.04). However, for periorbital wrinkles, WIR on the spot side was significantly larger than that on the linear side at 1 week ( P < 0.03). No significant difference was observed between the injection patterns in terms of muscle contraction and numeric rating scale pain scores.

Conclusions: Compared with the traditional spot injection, retrograde linear injection was superior in reducing forehead lines and glabellar lines, but less effective in reducing periorbital lines when identical dosages were injected.

Clinical question/level of evidence: Therapeutic, II.

Background: Many techniques have been used to treat trichiasis and distichiasis, but none of them are consistently successful, without complications, or effective in different severities. In addition, etiologic factors and their relationship with the severity or prognosis have not been identified in the non-trachoma-endemic area.

Methods: In this retrospective consecutive study, the authors enrolled patients with trichiasis or distichiasis who had undergone carbon dioxide laser ablation in their tertiary medical center between November of 2013 and May of 2022. Surgical success was defined as no regrowth of misdirected eyelashes for at least 3 months postoperatively. The authors recorded the success rate within 3 months and 1 year after 1 treatment session, and within 3 treatment sessions. The authors also investigated the relationship between etiologic factors, severity, and the success rate.

Results: The authors enrolled 216 eyelids of 137 patients (average age, 69.4 years; mean follow-up duration, 22.9 months). The major underlying causes of trichiasis and distichiasis were idiopathic (64.4%) and prior eyelid surgery (20.8%). More major trichiasis and distichiasis cases were observed among patients aged younger than 60 years than in patients aged 60 years or older (43% versus 21%; P < 0.01), and among patients with an underlying cause of prior eyelid surgery compared with patients with an idiopathic cause (42.2% versus 23.0%; P < 0.01). The success rates within 3 months, within 1 year after 1 treatment session, and within 3 treatment sessions were 87.5%, 76.2%, and 94.4%, respectively.

Conclusions: The authors demonstrate that idiopathic cause and prior eyelid surgery are common causes of trichiasis and distichiasis. Carbon dioxide laser ablation is a safe, effective, and efficient treatment modality.

Clinical question/level of evidence: Therapeutic, IV.

Background: Effective information transfer relies on the proper use of educational tools. Evaluating the quality of presentations permits us to improve educational materials in plastic surgery. The authors' aims were to assess the quality of presentations at a national hand surgery meeting, using a checklist of presentation standards from the literature, and to identify areas of improvement.

Methods: The study sample included presentations from the clinical papers sessions at the 2020 Annual Meeting of the American Society for Surgery of the Hand. A modified checklist based on the literature was used to assess the presentations. Two members of the research team extracted data from the included presentations, and disagreements were reviewed collaboratively.

Results: A total of 96 presentations were included in this sample. The mean number of deficiencies per slide set was approximately 9. Misused graphics, ambiguous content (eg, undefined abbreviations, undefined symbols), and overdetermined slides were the most common deficiencies identified in the sample. One-way analysis of variance of presenter role found a significant difference in the mean number of deficiencies ( F2,93 = 7.36; P = 0.001) among different types of presenters, with surgeon presenters exhibiting more deficiencies than students and other health care professionals.

Conclusions: The use of a checklist to evaluate a presentation helps cultivate more effective presentations in national meetings. A collaborative peer-review process, incorporating feedback from multiple trainees, audience members, and colleagues, facilitates effective information transfer through presentations.

Background: The driver of secondary lymphedema (SL) progression is chronic inflammation, which promotes fibrosis. Despite advances in preclinical research, a specific effector cell subpopulation as a biomarker for therapy response or stage progression is still missing for SL.

Methods: Whole skin samples of 35 murine subjects of a microsurgically induced SL model and 12 patients with SL were collected and their fibroblasts were isolated. These lymphedema-associated fibroblasts (LAFs) were cultured in a collagen I-poly-D-lysine 3-dimensional hydrogel to mimic skin conditions. Fibroblasts from nonlymphedema skin were used as negative control and transforming growth factor β (TGF-β)-stimulated fibroblasts were used to recreate profibrotic myofibroblasts. Quantitative immunocytofluorescence confocal microscopy analysis and invasion functional assays were performed in all subpopulations and statistically compared.

Results: In contrast to normal skin fibroblasts, LAFs exhibit α-smooth muscle actin-positive stress fibers and a reduced number of tight junctions in 3-dimensional hydrogel conditions. The switch from normal E-cadherin high phenotype to an N-cadherin high -E-cadherin low morphology suggests epithelial-to-mesenchymal transition for expansion and proliferation. This pathologic behavior of LAF was confirmed by live cell imaging analysis of invasion assays. The significant activation of markers of the TGF-β receptor 2-Smad pathway and collagen synthesis (HSP-47 [heat shock protein 47]) in LAFs supports epithelial-to-mesenchymal transition phenotypic changes and previous findings relating to TGF-β1 and fibrosis with lymphedema.

Conclusions: A characteristic SL myofibroblast subpopulation was identified and translationally related to fibrosis and TGF-β1-associated stage progression. This SL-related subpopulation was termed LAFs. A comprehensive stage-related characterization is required to validate LAFs as a reliable biomarker for SL disease progression.

Clinical relevance statement: The authors identify a cellular effector for fibrosis and stage progression of secondary lymphedema as a possible biomarker for surgical indication and therapy response.