Plastic and reconstructive surgery最新文献

Background: We investigated whether a lyophilized human amnion chorion membrane (LHACM), with amnion, intermediate, and chorion layers, could alter or improve hypertrophic scarring.

Methods: We utilized our previously published murine model to create human-like hypertrophic scars by applying mechanical tension over a healing HTS (Hypertrophic scar) wound. Treatment with subcutaneous LHACM allograft was administered prior to wound closure. Scars were explanted on day 19; imaged after Hematoxylin & Eosin, Masson's Trichrome, Picrosirius Red, and immunofluorescent staining; and analyzed with ImageJ, Matlab, CurveAlign, and CTfire.

Results: Mechanical strain induced hypertrophic scarring, consistent with our previously validated model, and served as a basis for evaluating the effects of LHACM treatment1. Mechanical strain created wider, deeper, and denser scars compared to no strain controls. Picrosirius Red analysis showed that LHACM altered collagen fiber architecture, promoting fibers that were less aligned, straight, and wide than controls. Mechanical strain increased TGFβ and αSMA myofibroblast signaling, while treatment with LHACM reduced TGFβ and αSMA expression.

Conclusions: Subcutaneous treatment with LHACM significantly reduced gross and histological scar formation and improved collagen fiber arrangement by altering TGFβ and myofibroblast expression. Since available preventative options for HTS remain limited, commercially available LHACM could potentially be utilized clinically in high-tension wound sites to prevent and/or treat HTS.

Summary: Computer-assisted surgery (CAS) has transformed jaw reconstruction, enabling one-stage functional reconstruction with fibula bone segmentation and dental implantation. However, virtual surgical planning (VSP) without consideration of perforator position and soft tissue can lead to a difficult flap inset. Despite the rapid development of bony planning in recent years, little progress has been made in planning soft tissue, which limits the predictable execution of the plan.An artificial intelligence-enabled automatic program for segmenting skin perforating vessels was developed. The models of skin perforating vessels were incorporated into the VSP workflow when designing osteotomy and dental implantation sites. During the surgery, the vessel models were automatically registered and projected onto the patient's skin for goggle-free augmented-reality (AR) flap design and harvest. Consecutive patients undergoing FFF reconstructions participated in this pilot study. The perforators identified by the AI program and during surgery were compared.Seventy-nine skin perforators in 26 consecutive patients were mapped out using the AI program and incorporated into the routine VSP workflow. No intraoperative adjustments to the plan were required due to the perforator location. The overall predictive accuracy of the skin perforator segmentation was 92.8%.For the first time, our study employed a combined AI and AR approach for preoperative planning and intraoperative execution of the soft tissue component in computer-assisted jaw reconstruction, demonstrating promising outcomes. This study demonstrated the potential of AI and AR to improve the predictability of functional jaw reconstruction.

Background: Corneal neurotization (CN) is a promising surgical intervention for neurotrophic keratopathy (NK). The objective of the current study was to generate the largest retrospective review of CN to date to characterize its safety, efficacy, and long-term clinical outcomes.

Methods: The study includes 58 eyes from 58 patients who underwent corneal neurotization at Duke University Hospital (48 surgeries) and the Leyngold Institute for Plastic Surgery (10 surgeries) by a single surgeon between 2016 and 2024. Demographic data and covariates including Mackie stage of NK, Cochet-Bonnet corneal sensation, best-corrected visual acuity (logMAR), ability to taper medical therapy, ability to reverse tarsorrhaphy, complications, other surface rehabilitative surgeries post-CN, and use of cenegermin were collected at preoperative, 6-12 month postoperative, and last (≥12 month) postoperative visits. Data were analyzed using descriptive and inferential statistics with GraphPad Prism version 9.0.

Results: Significant improvements in Mackie stage and corneal sensation were observed at both 6-12 months and last postoperative visits (median 30 months, IQR 19 months) compared to preoperative measures. No significant changes in best-corrected visual acuity were noted between any time points. Younger patients and those with peripheral NK etiologies (as opposed to central etiologies) showed greater improvement. Cenegermin did not significantly affect outcomes. Complications occurred in 4 patients, none of which were vision-threatening or disfiguring. Of those requiring additional rehabilitative ocular surgeries, 82% tolerated the procedures well without corneal decompensation.

Conclusions: Corneal neurotization is highly effective and well-tolerated for managing NK, promoting a robust ocular surface that facilitates future rehabilitative surgeries.

Purpose: Hormone therapy (HT) has become a mainstay in the treatment of receptor positive breast cancers. There have been conflicting reports regarding the effects of HT after autologous breast reconstruction (ABR), with some reports suggesting patients on HT have a higher risk of complication and flap failure, while other studies bolstering the peri-operative safety of HT. Here, we present a matched cohort analysis to determine if HT affects outcomes following ABR.

Method: A retrospective review was conducted of patients undergoing ABR between 2016-2020. Patients were split into two cohorts: those on HT and those not on hormonal therapy (NH), based on a 1:1 propensity match using variables known to be risk factors for complications following DIEP, including BMI, smoking, timing of reconstruction, mastectomy indication, history of radiation and diabetes.

Results: 85 patients were matched into the HT and NH cohorts. Overall, patients in the HT cohort were significantly more likely to develop a complication (HT: 28% vs NH: 15%; p=0.04). Incidence of intraoperative thrombosis was similar between the cohorts as was incidence of post-operative total flap loss. HT did have a significantly increased risk of venous thromboembolism (VTE) when compared to NH patients (HT: 7.0 % vs NH 0%; p=0.03).

Conclusion: This is the first study examining the effect of pre-operative hormonal therapy on ABR, with matched cohorts to control for comorbidities. HT patients had a significantly higher risk of complication and VTE, suggesting patients should discontinue hormonal therapy prior to surgery.

Reconstructing nerve gaps greater than 13-15 centimeters often requires vascularized nerve grafts. However, using the sural nerve presents a technical challenge due to the lack of a consistent adjacent artery. This study introduces various free vascularized sural nerve flap designs to overcome this limitation. From 2018 to 2020, six patients at Chang Gung Memorial Hospital underwent eight free vascularized sural nerve grafts reconstruction, including brachial plexus, median, ulnar, posterior tibial, and sciatic nerve reconstructions. Three types of flap designs were performed: shunt-restricted arterialized lessor saphenous venous flap, vascularized sural nerve graft, and chimeric flap with peroneal or posterior tibial artery perforator flap. Most flaps maintained circulation successfully, with only one requiring conversion due to thrombosis. Mild congestion occurred in some venous flaps but resolved spontaneously. Tinel's sign advanced progressively in all patients, suggesting active nerve regeneration. These findings demonstrate that free vascularized sural nerve flaps are a flexible and effective option for managing long nerve defects. Tailoring the flap design to the clinical context offers reconstructive surgeons with a versatile strategy for peripheral nerve repair. Level of Evidence: Level 4/highly experienced category.

Auricular microtia commonly presents with conductive hearing loss, imparting appearance and functional differences. Single-stage microtia reconstruction with porous polyethylene implant and vascularized temporoparietal fascia flap is frequently employed at our center. Bone conduction hearing devices (BCHD) have gained popularity to treat conductive hearing loss with increasing device sophistication. BCHD placement is typically done in a delayed fashion, but with recent FDA approval for children as young as 5 years old, it is possible at the time of external ear reconstruction. We present a novel technique modification allowing for concurrent single-stage ear reconstruction with BCHD placement and compare early outcomes between a series of five patients who underwent concurrent reconstruction and five who underwent staged reconstruction. All patients in both groups achieved adequate tissue healing with similar time course of recovery, with average follow-up of 4.3±2.4 months. One patient in the concurrent cohort experienced polyethylene exposure post-operatively, requiring debridement and secondary tissue-transposition revision but without effect on the BCHD. When comparing procedural length, concurrent procedure length was significantly shorter than total time for staged reconstruction and implant placement (304±61 vs. 459±51 minutes, p=0.002). Further, time from index procedure to BCHD activation was significantly shorter in the concurrent cohort as compared to the staged cohort (59±45 vs. 403±220 days, p=0.024). Overall, these preliminary findings suggest that performing concurrent single-stage polyethylene ear reconstruction and BCHD placement is feasible, reduces operative time, and did not result in excessive complications in this small series.

Background: Blind aspiration before surgical excision minimizes overall treatment costs for dorsal wrist ganglia. It is unclear whether this translates to volar wrist ganglia (VWG), as an ultrasound (US)-guided aspiration may be required to minimize risk of radial artery injury. We hypothesized that performing one aspiration prior to considering surgical excision will be more cost-minimal than immediate surgical excision.

Methods: A microsimulation decision analytic model was developed for four treatment pathways: 1) initial aspiration before proceeding to open excision, 2) aspiration prior to arthroscopic excision, 3) initial open excision, and 4) initial arthroscopic excision. The model concluded at VWG resolution, or a single failed open revision excision. We assumed all aspirations occurred at a separate visit under ultrasound guidance. Resolution rates following each treatment were pooled from the literature. Direct costs were derived from the literature and from our institution's cost database. Indirect costs were derived from the Bureau of Labor and Statistics. We performed one-way sensitivity analyses (OWSA) and threshold analyses on key input variables.

Results: Weighted averages for recurrence were 42 ± 8%, 27% ± 2%, and 2% ± 2% following aspiration, open excision, and arthroscopic excision, respectively. US-guided aspiration prior to open excision was the least costly treatment pathway ($2,106 ± $2,233 per resolved case). Initial arthroscopic excision was the costliest strategy ($7,293 ± $521). These findings were robust to all OWSA (including resolution rate and cost estimates).

Conclusions: To maximize value of care, one aspiration should be attempted prior to open VWG excision. The cost would be further reduced for hand surgeons who perform their own US-guided aspirations. The role of initial open or arthroscopic excision for VWG treatment is questionable from a cost standpoint.Level of Evidence: III, economic decision analysis.

Objectives: This systematic review and meta-analysis aimed to evaluate the impact of reduction mammaplasty (RM) on back pain and postural changes in patients with macromastia.

Methods: A comprehensive literature search (PubMed, Google Scholar, Embase, Scopus) was conducted in November 2024 according to the 2020 PRISMA statement. Both prospective and retrospective studies examining RM's effects on back pain and posture were included. Primary outcomes were changes in back pain, spinal alignment (thoracic kyphosis, lumbar lordosis), and postural control.

Results: 47 studies met the inclusion criteria for systematic review, with 25 contributing to different meta-analyses (n=4677). Mean age was 38.6 (±3.0) years, BMI 27.57 (±2.06) kg/m^2, and follow-up 27.4 (±25.5) months. All studies assessing back pain reported relief following RM.Meta-analysis of 7 studies (n=393) using the Visual Analog Scale showed a significant reduction in back pain (mean difference: 5.01, 95% CI: 3.11-6.91, p<0.01). A separate quantitative analysis of 12 studies (n=1380) using a dichotomous endpoint (improvement in back pain vs. no improvement) found 90% of patients experienced significant back pain relief (95% CI: 86%-93%). Thoracic kyphosis, assessed in 4 studies (n=126), improved significantly (mean difference: 1.5°, 95% CI: 0.23-2.76, p=0.02), whereas changes in lumbar lordosis (n=126) were less consistent (mean difference: 0.26°, 95% CI: -0.07-0.60, p=0.13). Postural control data are exploratory due to the limited number of comparable studies.

Conclusion: RM appears to be an effective intervention for alleviating chronic back pain and improving thoracic kyphosis in patients with macromastia. Further research is needed to clarify its effects on postural control.

Level of evidence: Level II.

Background: Although breast augmentation for ptosis correction has significant advantages and achieves favorable outcomes in specific indications, for patients with large breast volume or significant ptosis, implant alone often fails to provide adequate lift and may worsen the degree of ptosis. This study summarizes the clinical experience and key points of our institution in performing secondary mastopexy via the lollipop incision technique.

Methods: This was a single-center retrospective study that included patients who underwent explantation combined with lollipop incision mastopexy after unsatisfactory breast augmentation from October 2019 to October 2024. The analysis included baseline demographic data, breast ptosis correction assessment parameters, and BREAST-Q domain scores. At the final follow-up, corrective outcomes, aesthetic results, and patient satisfaction were evaluated.

Results: Twenty-three patients underwent secondary mastopexy for correction. Postoperatively, the distance from the nipple to the inframammary fold (N-IMF), the distance from the sternal notch to the nipple (S-N), the distance from the clavicle to the nipple (C-N), and the base width of the breast (BW) all decreased significantly (all P < 0.001), resulting in successful ptosis correction in every case. Moreover, BREAST-Q assessments demonstrated significant improvement over preoperative scores, including satisfaction with breasts (P < 0.001), psychosocial well-being (P < 0.001), physical well-being: chest (P = 0.002), and sexual well-being (P = 0.007).

Conclusions: Our results demonstrate that secondary mastopexy using the explantation combined with lollipop incision technique is a reliable approach for managing failed breast augmentation in the correction of ptosis. Patients who required glandular reshaping and skin redraping achieved good aesthetic outcomes.

Clinical question/level of evidence: Therapeutic, IV.

Trial registration: ChiCTR2500097610.

Objective: To investigate the changes in the location of the modiolus, a fibromuscular structure between the orbicularis oris and lip dilator muscles, with aging in Asian individuals.

Methods: The position of the modiolus was evaluated using ultrasound imaging in 45 young (20s) and 45 elderly (80s) Asian participants of both sexes.

Results: A statistically significant (p<0.05) downward and inward shift in the location of the modiolus was observed with aging.

Conclusion: The aging process is associated with laxity of the lip elevator muscles and increased contracture of the lip depressor muscles, as indicated by the changes in modiolus position. These findings may have implications for facial rejuvenation procedures.