Plastic and reconstructive surgery最新文献

Background: There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plate fixation. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate and determine stability differences between patient-specific and stock plates.

Methods: Consecutive patients with cleft lip and palate who underwent isolated LFI by one surgeon (B.L.P.) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (nasion to A point) and horizontal planes (basion to A point) at 1 year after LFI using 3-dimensional cone beam computed tomography. Statistical analysis included independent samples t , Mann-Whitney U , Fisher exact, and chi-square tests. Values of P < 0.05 were significant.

Results: The sample included 63 subjects; 23 in the patient-specific group (36.5%) and 40 in the stock group (63.5%). Groups were comparable by sex, race, age at surgery, cleft type, presence of pharyngeal flap, and magnitude of horizontal movement ( P > 0.136 for all). Subjects who underwent patient-specific plate fixation were less likely to have greater than or equal to 1-mm change at 1 year in the horizontal (4.3% versus 50.0%; P < 0.001) and vertical planes (4.3% versus 65.0%; P < 0.001) compared with stock plates. For patients who had greater than 10-mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific plates, 0.105 ± 0.317 mm; stock plates, 1.888 ± 1.125 mm; P = 0.003).

Conclusion: Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after 1 year than stock plates.

Clinical question/level of evidence: Therapeutic, III.

Background: Reconstructive surgery has experienced a paradigm shift in favor of free flaps. Yet local flaps may be of particular use in foot and ankle reconstruction among comorbid patient populations. Thus, the authors sought to better characterize long-term outcomes in this setting.

Methods: A single-center, retrospective cohort study of patients undergoing local muscle and fasciocutaneous flaps of the foot and ankle from January of 2010 through November of 2022 was performed. Flaps were performed on wounds measuring 3 × 6 cm or smaller; flap selection depended on preoperative vascular assessment, Doppler findings, comorbidity profile, and wound location, depth, and geometry.

Results: A total of 206 patients met inclusion criteria. Their median age was 61.0 years (interquartile range, 16.8), and comorbidities included diabetes mellitus ( n = 149 [72.3%]) and peripheral arterial disease ( n = 105 [51.0%]). Presentations included chronic, nonhealing wounds ( n = 77 [39.1%]) or osteomyelitis ( n = 45 [22.8%]) and most frequently extended to the bone ( n = 128 [62.1%]). Eighty-seven patients (42.2%) received muscle flaps; 119 (57.8%) received fasciocutaneous flaps. Six patients (2.9%) needed return to the operating room, with thrombosis occurring in 2 cases (1.0%). The flap success rate was 98.1%. By a median follow-up duration of 21.7 months (interquartile range, 39.0), 21.8% of patients ( n = 45) required ipsilateral amputation, 73% ( n = 145 of 199) were ambulatory, and 2 deaths related to the surgical wound occurred (2 of 49 [4.1%]). Multivariate analysis revealed that positive predictors of complications included diabetes mellitus, end-stage renal disease, and history of venous thromboembolism or smoking.

Conclusion: Local flaps remain a reliable option to reconstruct smaller defects of the foot and ankle in a highly comorbid population.

Clinical question/level of evidence: Therapeutic, IV.

Learning objectives: After studying this article, the participant should be able to: 1. Describe indications and patient factors relevant to performing prepectoral breast reconstruction. 2. Understand the effects of different types of implants and implant support in prepectoral breast reconstruction. 3. Describe techniques for surgical revision to improve outcomes in prepectoral breast reconstruction. 4. Understand the current literature surrounding clinical and quality-of-life outcomes in prepectoral breast reconstruction.

Summary: This article goes beyond a general review of prepectoral breast reconstruction, providing a working framework and important considerations for any surgeon utilizing prepectoral breast reconstruction techniques. This article also addresses current controversies, provides practice tips and technical pearls, and addresses gaps in knowledge with both opinion and a review of the most current literature.

Background: This study aimed to investigate the optimal surgical techniques in reduction malarplasty by comparing the difference between the L-shaped osteotomy with vertical and oblique bone resection.

Methods: A total of 120 patients who visited the authors' department for L-shaped osteotomy with either vertical (group I) or oblique bone resection (group II) from 2015 to 2021 were reviewed retrospectively. The preoperative and postoperative spiral computed tomographic data were analyzed. The preoperative computed tomographic data were also used to simulate the virtual and model surgery.

Results: The results showed that a broken bridge-like structure with a bony gap of 2.86 ± 1.03 mm at the zygomatic arch root was observed in group I, and a mortice-and-tenon joint structure with a bone overlap of 2.28 ± 0.58 mm was formed in group II. The zygoma in group I displaced significantly in the vertical direction and horizontal direction during the follow-up. Simultaneously, the incidence of complications was higher in group I. In the mechanism analysis through virtual and model surgery, the zygomatic segment was shifted anteriorly and inferiorly in group I, and a bony gap was detected at the zygomatic arch root. Conversely, a superior and posterior movement was performed in group II and it maintained the zygomatic complex integral with bone overlap at the zygomatic arch root on repositioning.

Conclusion: This study suggested that L-shaped osteotomy with oblique bone resection could be the optimal choice for reducing zygomatic prominence.

Clinical question/level of evidence: Therapeutic, III.

Background: In performing a neck lift, the size and location of the submandibular gland (SMG) must be evaluated to achieve the ideal neck contour. Many surgeons, however, avoid SMG excision because of the technical difficulty and risks of hematoma and nerve damage. LigaSure (Valleylab, Boulder, CO) is a bipolar energy-based instrument that permanently seals vessels and connective tissue. Its use can make the SMG excision step easy and safe by reducing surgical risks.

Methods: A total of 83 patients who underwent SMG excision between 2018 and 2022 were included in the study. All patients' SMGs were partially excised using the LigaSure device, and the complication rates were documented.

Results: Patients were followed up for an average period of 21 months (range, 9 months to 2.4 years). No perioperative intraglandular bleeding or postoperative hematoma was observed in any patient. No sialoma cases were observed postoperatively. Only 3 patients underwent repeated seroma aspirations. Transient lower lip weakness was observed in 7 patients, who all recovered in the first 6 months postoperatively.

Conclusion: LigaSure-assisted SMG excision in deep-plane neck lift surgery was found to be technically easier to perform, time saving, safe, and highly effective in preventing hematoma and intraoperative bleeding.

Clincal question/level of evidence: Therapeutic, IV.

Background: Step-off deformity is a suboptimal aesthetic outcome at the donor site following abdominal flap harvesting for breast reconstruction. This study assessed the prevalence of step-off deformities after autologous breast reconstruction and explored the associated risk factors.

Methods: This retrospective study evaluated step-off deformities among consecutive patients who had undergone autologous abdominal flap-based breast reconstruction between January of 2019 and December of 2022. The postoperative evaluation used medical records and photographs, defining step-off deformity as a thickness discrepancy in the upper and lower abdominal tissue with reference to the scar line and angles less than 165 degrees. Moreover, the study explored potential risk factors, including abdominal subcutaneous tissue thickness based on computed tomography.

Results: In total, 187 patients underwent abdominal flap-based breast reconstruction; 38 exhibited step-off deformity. The case group exhibited significantly higher body mass index (BMI) and greater subcutaneous layer thickness in both the upper and lower abdomen compared with those of the control group. The groups did not differ significantly in postoperative complications, including abdominal bulging or hernia. Multivariable analysis revealed notable risk factors for step-off deformity development: BMI ( P = 0.026), presence of preoperative abdominal fold ( P = 0.028), and thickness differences between the upper and lower abdomen ( P = 0.011). The cut-off values were 26.1 kg/m 2 for BMI and 9.5 mm for thickness differences.

Conclusions: Higher BMI, presence of abdominal fold, and significant upper-lower abdomen tissue thickness differences may be associated with an increased risk of donor step-off deformity after abdominal flap harvest. These findings may inform patient counseling and warrant attention when closing donor wounds in high-risk individuals.

Clinical question/level of evidence: Risk, III.

Background: Numerous complications are reported following interventions for Dupuytren contracture; however, their incidence, management, and outcomes remain poorly reported. The aims of this review were to report the proportions of complications, compare likelihood of complications between interventions, and evaluate reporting.

Methods: Patient demographics, interventions, complications, their management, and outcomes were extracted. Analysis of descriptive data enabled review of reporting. Meta-analysis (MA) of noncomparative data sets enabled estimation of proportions of patients experiencing complications. Network meta-analysis (NMA) of comparative studies estimated the relative occurrence of complications between interventions.

Results: Twenty-six studies, comprising 10,831 patients, were included. Interventions included collagenase injection, percutaneous needle fasciotomy (PNF), limited fasciectomy (LF), open fasciotomy (OF), and dermofasciectomy (DF). Overall quality and consistency of outcomes reporting was poor. MA enabled estimates of probabilities for 3 common complications across all interventions; the reported rates for LF were 4.5% for infection, 3% for nerve injury, and 3.3% for CRPS. LF, the most common intervention, was used as the reference intervention for comparison of the most common complications via NMA, including hematoma (OF odds ratio, 0.450 [95% CI, 0.277 to 0.695]; PNF odds ratio, 0.245 [95% CI, 0.114 to 0.457]), infection (PNF odds ratio, 0.2 [95% CI, 0.0287 to 0.690]; DF odds ratio, 2.02 [95% CI, 1.02 to 3.74]), and neurapraxia [PNF odds ratio, 0.0926 [95% CI, 0.00553 to 0.737]).

Conclusions: There was limited reporting of complication occurrence, management, and outcomes, contributing to a gap in information for informed patient consent. MA was possible for reporting of proportions for infection, nerve injury, and CRPS. NMA enabled direct comparison of the 6 most common complications between interventions. Improving consistency and quality in complications reporting aids counseling of patients regarding the true rates and consequences of the risks of interventions, which can guide selection.

Background: In 2021, the United States enacted a law requiring hospitals to report prices for health care services. Across several health care services, poor compliance and wide variation in pricing was found. This study was performed to investigate variation in reporting and listed prices by hospital features for high-volume hand procedures, including carpal tunnel release, trigger finger release, de Quervain tenosynovitis release, and carpometacarpal arthroplasty.

Methods: The Turquoise Health price transparency database was used to obtain listed prices and linked to hospital characteristics from the 2021 Annual American Hospital Association Survey. This study used descriptive statistics and generalized linear regression.

Results: The analytic cohort included 2652 hospitals from across the United States. The highest rate of price reporting was in the Midwest (52% [ n = 836]) and lowest in the South (39% [ n = 925]). Compared with commercial insurers ($3609 [95% CI, $3414 to $3805]), public insurance rates were significantly lower (Medicare: $1588 [95% CI, $1484 to $1693], adjusted difference -$2021, P < 0.001; Medicaid: $1403 [95% CI, $1194 to $1612], adjusted difference -$2206, P < 0.001). Listed rates for self-pay patients were not statistically different from commercial rates.

Conclusions: Although pricing for high-volume elective hand procedures is frequently reported, a high proportion of hospitals do not report prices. These data highlight the need for future transparency policy to include pricing for high-volume hand surgery to give patients the ability to make financially informed choices. These results are a valuable aid for surgeons and patients to promote financially conscious decisions.