Plastic and reconstructive surgery最新文献

Learning objectives: After studying this article, the participant should be able to: (1) Understand the unique differences between mastopexy in aesthetic and reconstructive breast surgery. (2) Describe the approach to performing mastopexy with autoaugmentation or after explantation. (3) Have insight into the approach and decision-making process for performing mastopexy with nipple-sparing mastectomy. (4) Apply the mastopexy skin reduction techniques to ptotic women undergoing postmastectomy breast reconstruction.

Summary: Techniques and indications for mastopexy are expanding. In aesthetic surgery, access to supportive meshes and higher rates of breast implant explantation without replacement contribute to this. In breast reconstruction, higher rates of nipple-sparing mastectomy and higher expectations for cosmetically favorable outcomes with ptotic breasts are key drivers. A keen understanding of the available blood supply and how it may change over time with a staged approach, thoughtful use of otherwise-discarded tissues, and judicious application of mesh support are important new considerations for plastic surgeons to apply to traditional mastopexy. This evidence-based article focuses on specific aesthetic and reconstructive mastopexy techniques associated with autoaugmentation, explantation, and nipple-sparing mastectomy.

Background: Rib cage remodeling has shown promising aesthetic results as a new technique for body contouring, and yet risks and complications associated with the procedure have not been well established. The aim of the authors' study was to assess safety, efficacy, and patient satisfaction rate associated with a new surgical technique for waistline definition.

Methods: The authors looked into their records for patients who underwent waist narrowing through a new rib remodeling procedure with osteosynthesis of ribs XI and XII from October of 2022 to June of 2023. Follow-up was carried out at 1 and 3 months after surgery. Outcomes were evaluated based on waist and hip measurements, body image, pain, and a patient satisfaction survey.

Results: A total of 27 consecutive patients were included in the analysis. The authors' technique resulted in a significant reduction in waist circumference, as evidenced by a decrease of 12.1 cm and 13.0 cm at the first and third months, respectively ( P < 0.005). A reduction of hip circumference of 6.2 cm and 8.7 cm at the first and third months, respectively, was also reported. A high patient satisfaction rate was reported. Postoperative complications included only 1 case of wound dehiscence and 1 case of mild pain. Pain levels were also reduced, with a mean pain score of 2.4 at week 1 and 0.26 at month 1.

Conclusions: Rib osteotomy with osteosynthesis emerges as an innovative, safe, and reliable approach for waist narrowing. The authors' results suggest that this technique can be applied to a wide variety of patients, and it might entail significant advantages compared with other techniques.

Clinical question/level of evidence: Therapeutic, IV.

Background: Macromastia can limit a woman's ability to exercise. Reduction mammaplasty has been reported to subjectively improve exercise capability and stimulate weight loss. Considering the lack of published quantitative data, the authors sought to examine change in weight and body mass index (BMI) in adolescent women following reduction mammaplasty.

Methods: Retrospective chart review was performed of patients younger than 21 years who underwent reduction mammaplasty at the authors' institution from 2015 through 2019.

Results: Fifty-six patients with follow-up weight measurements were included in the analysis. The median follow-up time was 46.0 months. Only 22 patients (39.3%) experienced a decrease in BMI at final follow-up compared with baseline. Patients classified as having a healthy weight preoperatively (BMI, 18.5 to 24.9 kg/m 2 ) experienced a significant increase in BMI at 2-year, 3-year, 5-year, and final postoperative follow-up visits, compared with baseline. Patients classified as overweight (BMI, 25.0 to 29.99 kg/m 2 ) or obese (≥30 kg/m 2 ) did not experience significant BMI change at final postoperative follow-up.

Conclusions: BMI and weight trended upward postoperatively regardless of BMI classification. Reduction mammaplasty alone is not sufficient to stimulate weight loss. Healthy lifestyle changes should be encouraged to help prevent weight gain in adolescent women following reduction mammaplasty.

Clinical question/level of evidence: Therapeutic, IV.

Background: Breast cancer-related lymphedema is a common complication lacking medical treatment. Lymfactin is an adenovirus type 5-based gene therapy and prolymphangiogenic growth factor vector that induces vascular endothelial growth factor C expression. The authors' aim was to evaluate the therapeutic effect of Lymfactin with vascularized lymph node transfer (VLNT).

Methods: This phase II, double-blind, placebo-controlled, randomized, multicenter study evaluated the efficacy and safety of Lymfactin in combination with VLNT. The primary endpoints were edema volume, quality of life, and lymphoscintigraphy. All adverse events were recorded. A mixed model of repeated measures analysis of covariance was performed. This study was a continuation of a previous phase I Lymfactin study.

Results: Thirty-nine patients with breast cancer-related lymphedema were recruited between June of 2018 and December of 2019 and randomized to receive either Lymfactin ( n = 20) or placebo ( n = 19). The primary endpoints showed a positive effect of VLNT in both groups compared with the baseline, but without statistical differences between groups at 12 months. In addition, greater improvements were observed in the tissue dielectric constant ratios measuring skin interstitial fluid levels in the Lymfactin group compared with the placebo group ( P = 0.020). No differences in adverse events were detected between the groups.

Conclusions: This study was one of the few studies to objectively show a positive effect of VLNT in a prospective, clinical, multicenter setting. It was also the first-ever randomized prospective clinical study showing a quantitatively positive effect of a medical therapy on the edema of lymphedema but failed to show differences between groups in primary outcome measures.

Clinical question/level of evidence: Therapeutic, II.

Background: Autologous breast reconstruction (ABR) may confer higher patient-reported outcomes than implant breast reconstruction, but an in-depth examination of factors associated with satisfaction after ABR is lacking. The authors aimed to determine independent predictors of 1-year satisfaction with breasts after ABR and assess the importance of elective procedures on satisfaction.

Methods: A retrospective analysis of patients who underwent abdominally based ABR between 2010 and 2021 and completed the BREAST-Q Satisfaction with Breasts module at 1 year was performed. Elective procedures consisted of breast revision and nipple-areola complex reconstruction.

Results: A total of 959 patients were included. Satisfaction with Breasts score improved from 53 (interquartile range [IQR], 44 to 64) preoperatively to 64 (IQR, 53 to 78) at 1 year postoperatively ( P < 0.001). Factors significantly associated with decreased postoperative score included lower preoperative scores (β = 0.19 [95% CI, 0.08 to 0.31]; P = 0.001), older age (β = -0.17 [95% CI, -0.34 to -0.01]; P = 0.042), Asian race (versus White, β = -6.7 [95% CI, -12 to -1.7]; P = 0.008), and a history of psychiatric diagnoses (β = -3.4 [95% CI, -6.2 to -0.66]; P = 0.015). Patients who received radiation therapy (β = -5.6 [95% CI, -9.0 to -2.3]; P = 0.001) or had mastectomy skin flap/nipple necrosis (β = -3.8 [95% CI, -7.6 to -0.06]; P = 0.046) also had significantly decreased scores. Satisfaction with Breasts scores improved significantly after breast revision procedures (from 54 [IQR, 42 to 65] to 65 [IQR, 54 to 78]; P < 0.001), and nipple-areola complex reconstruction (from 58 [IQR, 47 to 71] to 67 [IQR, 57 to 82]; P < 0.001).

Conclusions: Multiple independent patient and treatment level factors are associated with lower 1-year Satisfaction with Breasts scores following ABR. Elective procedures have the potential to improve satisfaction. Understanding these findings is imperative for optimizing clinical decision-making and managing expectations.

Clinical question/level of evidence: Risk, III.

Background: More than 250,000 patients undergo bariatric surgery each year in the United States. Approximately 21% will undergo subsequent body contouring after massive weight loss. Patients with prior bariatric surgery are at a greater risk for complications relative to the general population. However, it is unknown whether bariatric surgery type is associated with differential complication risk after panniculectomy.

Methods: A retrospective chart review of postbariatric patients who underwent abdominal panniculectomy at a single large quaternary care center was performed. Postoperative complications were graded according to the Clavien-Dindo classification. Descriptive statistics, multivariable logistic regression, and power calculations were performed.

Results: In total, 216 patients were included. Restrictive bariatric surgery accounted for 48.6%, whereas 51.3% had a history of malabsorptive bariatric surgery. The overall rate of complications was 34.3% (restrictive, 36.2%; malabsorptive, 32.8%; P = 0.66). Wound complications were observed in 25.5% ( n = 55) of patients. Systemic complications occurred in 11.1% of patients overall, with statistically similar rates between restrictive and malabsorptive groups. After adjusting for both patient and operative factors, no significant difference in total complications (OR, 1.15; 95% CI, 0.47 to 2.85; P = 0.76), systemic complications (OR, 0.26; 95% CI, 0.05 to 1.28; P = 0.10), or wound complications (OR, 2.31; 95% CI, 0.83 to 6.41; P = 0.11) was observed.

Conclusions: Complication rates following panniculectomy in bariatric surgery patients are high and predominantly related to wound healing. No significant difference between type of bariatric surgery and complication risk was found.

Clinical question/level of evidence: Therapeutic, III.

Background: The correction of severe blepharoptosis is one of the most challenging operations in plastic surgery. This study introduces a novel self-reinforced fixation technique combining the levator complex with conjoint fascial sheath for the correction of severe blepharoptosis and reviews the postoperative results over the preceding 12 years.

Methods: This retrospective review included all patients who underwent self-reinforced fixation with or without conjoint fascial sheath at the authors' center between 2010 and 2022. The clinical data of the 2 groups were collected and evaluated.

Results: All patients were followed up for 6 months to 8 years postoperatively. The mean postoperative marginal reflex distance 1 and levator function increased significantly in both groups. Sufficient correction of ptosis was achieved in 32 (65.31%) and 84 (81.56%) eyelids in groups I and II, respectively. The mean eyelid lagophthalmos was 1.27 ± 0.91 mm and 0.85 ± 0.89 mm in groups I and II, respectively. The most common complication was undercorrection of ptosis, which was observed in 14 eyelids (28.57%) and 15 eyelids (14.56%) in groups I and II, respectively.

Conclusions: The self-reinforced fixation technique was effective in correcting severe congenital ptosis in Chinese patients. The clinical effect was consistent in the long-term follow-up cases, and the recurrence rate was low. Thus, this technique can enhance the strength of the levator muscle and maintain appropriate elasticity of eye closure.

Clinical question/level of evidence: Therapeutic, III.