Plastic and Reconstructive Surgery Global Open最新文献

Background: Ventral hernia repair is inherently prone to recurrence. This article is a practical review that summarizes the literature on the biomechanics of ventral hernia repairs to provide clinically applicable, evidence-based recommendations to reduce hernia recurrence.

Methods: A practical review of all relevant literature in PubMed concerning the mechanics of ventral hernia repairs and the forces involved was conducted in August 2023.

Results: Of the 598 full-text publications retrieved, 29 satisfied inclusion criteria. Among these, 5 articles included enough numeric data for a quantitative analysis of the ultimate tensile strength of the layers of the abdominal wall.

Conclusions: The utilization of mesh in ventral hernia repairs is recommended to strengthen weakened abdominal wall tissue. It is essential to primarily close the anterior sheath with a robust mesh-tissue overlap to promote "load-sharing" between the mesh and the abdominal wall. This approach reduces mesh deformity and stress on fixation points, leading to lower hernia recurrence rates. Minimizing mesh fixation (when placed in the retromuscular plane) can reduce postoperative pain and hospital stay without significantly affecting hernia recurrence. Orienting mesh according to abdominal anisotropy is crucial for reducing mesh stiffness, improving healing, and preventing recurrence. Future studies with advanced computer modeling will continue to provide further insights into mesh biomechanics and abdominal wall healing.

Background: Little is known about the actual composition of prominent orbital fat pads. It was incidentally noted that hyaluronidase injections in prominent lower eyelid fat pads attenuated them, suggesting prevalence of hyaluronic acid (HA), and raising questions regarding their etiology. This led to 2 institutional review board studies: The first quantified HA concentration in orbital fat pads and assessed possible correlation between HA levels and degree of lower eyelid puffiness. The second determined if regular hyaluronidase injections in prominent lower eyelid fat pads impacted their size to uncover a possible role of intrinsic HA and its hydrophilic properties in their etiology.

Methods: Lower eyelid orbital fat harvested from 20 filler-naive blepharoplasty patients underwent enzyme linked immunosorbent assay for HA quantification. A separate group of 14 filler-naive patients requesting nonsurgical treatment of lower eyelid puffiness were treated with a series of hyaluronidase injections.

Results: HA levels in prominent eyelid orbital fat pads averaged 39.3 µg/mg of the dry weight, higher than reported in other solid human tissues. Orbital fat HA levels correlated with the degree of clinical puffiness. Hyaluronidase attenuated lower eyelid puffiness in 78.6% of patients. The extent and duration of improvement varied between responders but increased with repetitive injections.

Conclusions: Prominent orbital fat pads have a higher HA concentration than reported in other solid human tissues. HA hydrophilic properties likely contribute to fat pad edema manifesting as puffiness. Attenuation of prominent lower eyelid fat pads following hyaluronidase injections further implicates intrinsic HA in the etiology of prominent eyelid fat pads.

Background: Local flaps are commonly used for reconstruction of digital soft-tissue defects. There remains a paucity of options available for small finger volar and dorsal soft-tissue defects distal to the proximal interphalangeal joint. The purpose of this study was to analyze perforators along the hypothenar palmar region arising from the artery of the ulnar side of the small finger as it comes off the superficial palmar arch for consistency and potential to be used for perforator-based flap reconstruction of soft-tissue defects and joint coverage of the small finger.

Methods: Four cadaveric upper extremities were injected with Microfil silicone injection compound. Dissection was performed from the superficial palmar arch to the ulnar digital artery of the small finger, and perforators were identified and analyzed for consistency and utility. Flap elevation was performed based on these perforators in a small finger reverse ulnar digital artery fashion.

Results: All cadaveric dissections showed a suitable perforator pattern along the hypothenar palmar region with a minimum of 5 perforators available from which to base a flap to address dorsal and volar defects of the small finger. Two clinical examples are presented confirming the viability and utility of this flap.

Conclusions: A detailed anatomic study with 2 clinical examples of this retrograde pedicle island flap is presented. The small finger reverse ulnar digital artery hypothenar palmar-based perforator flaps are a viable option with a reliable perforator pattern, providing a functional solution for reconstruction of soft-tissue defects and joint coverage of the small finger.

Genital lymphedema is a challenging condition often refractory to conservative treatments. This case report presents a novel surgical approach combining a lymphatic system transfer based on a pedicled superficial circumflex iliac perforator flap with nanofibrillar collagen scaffolds to address genital lymphedema secondary to hidradenitis suppurativa. A 47-year-old man with hidradenitis suppurativa-related genital lymphedema, unresponsive to conservative measures, underwent the procedure. Indocyanine green lymphography and ultrahigh-frequency ultrasound were used for preoperative flap planning, including lymphatic vessels in the skin paddle. Nanofibrillar collagen scaffolds were placed to enhance lymphangiogenesis in distal genital areas. The patient experienced significant improvement, with a reduction in lymphedema severity from 5 of 9 to 1 of 9 on the Genital Lymphedema Score and substantial relief of symptoms. Single-photon emission computed tomography demonstrated uptake of ¹⁸F-fluorodeoxyglucose at the right inguinal lymph nodes, ipsilateral to the lymphatic flap. This case demonstrates the potential of this combined approach in managing complex genital lymphedema.

Background: Advances in surgical planning and 3-dimensional (3D) printing have benefitted the field of craniomaxillofacial surgery by allowing visualization of patient anatomy in settings of otherwise restricted surgical fields. Long 3D print times limit the usability of surgical planning workflows in acute trauma reconstruction. We sought to identify variables affecting print time and produce rapid-printed models with sufficient quality for prebending osteosynthesis plates.

Methods: Three-dimensional printing variables, including resolution, print orientation, and region of interest cropping, were optimized on a single mandibular and midface fracture model to maximize print time efficiency. Five mandibular and 5 midface fractures were printed both in the high-resolution and time-efficient protocol. Fixation plates were contoured to fit the optimized models and computed tomography scan. Distances and volumes between the fracture surface and plate were computed.

Results: High-resolution mandible models were printed in 7.47 hours and maxillae in 7.53 hours. Optimized models were printed in 0.93 and 1.07 hours, respectively. Cropping to regions of interest, rotating the model, and decreasing print resolution significantly reduced print time. The difference (optimized versus high resolution) in distance between the plate and model averaged 0.22 and 0.34 mm for mandibles and maxillae; the air space volume differed by 1.39 and 0.90 mm³, respectively.

Conclusions: Adjusting size, resolution, and position on the printing platform allows rapid fabrication of 3D models for surgical reconstruction without sacrificing surface quality. These edits reduce printing time, enabling the implementation of 3D-printing workflows for surgical planning in acute craniomaxillofacial trauma settings.

Background: Poland syndrome (PS) is a rare congenital syndrome characterized by unilateral pectoralis major muscle defect. In 2016, we proposed the thorax, breast, and nipple-areola complex (TBN) classification and a subsequent treatment algorithm, which included conservative and surgical procedures. Our aim is to report the results we obtained treating all thoracic anomalies according to the proposed algorithm in a cohort of adolescents affected by PS.

Methods: Between January 2016 and June 2023, 52 patients with PS were treated using the TBN classification in our institute. Each patient was evaluated by a multidisciplinary team composed of pediatric and plastic surgeons and treated according to the algorithm. Surgical procedures included were minimally invasive pectus excavatum repair, open sternochondroplasty, patch, metal plate, 3-dimensional chest wall prosthesis, fat grafting, tissue expanders, and breast and pectoral implants. Conservative treatments included vacuum bell and corset.

Results: Half of the patients had no thoracic skeletal defect (T1), but all had soft-tissues defects. Nineteen patients required thoracoplasty, all of whom experienced T downstaging after treatment, and 90% were postoperatively reclassified as T1. Conservative treatment for T correction was proposed in 8 patients; 83% underwent fat grafting, and 88% had a breast/pectoral prosthesis implanted. There were no major complications registered. The mean follow-up was 5.9 years.

Conclusions: The proposed algorithm can be considered a useful tool for standardized surgical decision-making in PS. Fat grafting can play a major role in a pediatric setting. A multidisciplinary and minimally invasive approach, whenever possible, should be prioritized in patients younger than 18 years.

Background: There is no consensus about the best treatment for Dupuytren contracture in the hand. In particular, whether to use a percutaneous needle fasciotomy (PCNF) in preference to a limited fasciectomy (LF).

Methods: We performed a retrospective review of the outcomes of 74 joints treated with either PCNF or LF. Baseline characteristics, complications, and active extension deficit (AED) were assessed at 3 weeks and 3 months posttreatment. Reoperative procedures were analyzed to assess the effectiveness of repeated procedures.

Results: Our results suggest that there is no significant difference between PCNF and LF in reducing AED at 3 weeks (P = 0.504) or 3 months (P = 0.66). Moreover, our data suggest that the risk of a surgical complication was the same for both procedures, after adjustment for confounders (P = 0.613). Our study suggests that a reoperative PCNF was 15.3% less effective in reducing the AED compared with a primary PCNF at 3 months postoperatively (P = 0.032); whereas there was no change in the effectiveness of a reoperative LF in reducing AED at both 3 weeks (P = 0.839) and 3 months (P = 0.449).

Conclusions: We believe that PCNF should be used as the primary treatment for nonrecurrent and recurrent Dupuytren contractures. More frequent use of PCNF may help to reduce waiting times for treatment and may enable better resource allocation. Further prospective studies should be carried out.

Background: Patients who require surgical treatment for diabetic foot ulcer (DFU) or chronic limb-threatening ischemia (CLTI) are often in generally poor condition and have complications. General anesthesia may be risky in surgery for such patients. Thus, the authors perform surgery using peripheral nerve block under dexmedetomidine sedation for patients with DFU and CLTI.

Methods: This study evaluated intraoperative stress, anxiety, and safety in 18 patients undergoing peripheral nerve block with dexmedetomidine. Sedation levels were assessed using the observer's assessment of alertness/sedation (OAA/S) score on a 5-point scale from 5 (awake) to 1 (deeply sedated). Postoperatively, a questionnaire was administered to assess intraoperative stress and memory. Intraoperative stress was assessed using a 6-point face scale (0 to 6: not at all to unbearably high), and intraoperative memory was rated on a 5-point numeric scale (1 to 5: no memory to everything).

Results: The intraoperative OAA/S score was 3-5, indicating that appropriate sedation was obtained. The mean intraoperative stress score was 0.72 (range: 0-3), and the mean intraoperative memory score was 2.44 (range: 1-4). One patient had bradycardia and 9 had hypoxemia. All of these cases were improved by decreasing the dose of dexmedetomidine and encouraging deep breathing on call.

Conclusions: These results suggest that this procedure is a useful method to reduce patient burden and alleviate stress and anxiety during surgery. However, dexmedetomidine may cause hypoxemia in patients with DFU or CLTI; thus, attention should be paid to hypoxemia and countermeasures should be taken against this adverse effect.

Background: Nasal tip projection ideals have been based on the Caucasian nose; however, many racial groups have underprojected tips. Several methodologies have been described to measure ideal nasal tip projection. This study aimed to compare various methods to racially diverse groups to elucidate those best suited for race-specific facial morphology.

Methods: An openly accessible artificial intelligence image generator was used to generate images of Caucasian, Middle Eastern, and African American noses. Tip projection was manually measured using 5 different ideal tip projection methods. One-way analysis of variance with post hoc Tukey honest significant difference test evaluated differences between racial cohorts. One-sample t tests were used for comparisons to previously described aesthetic ideals, and a P value of less than 0.05 was considered statistically significant.

Results: Twenty lateral images were analyzed per racial cohort (10 men and 10 women). All racial groups-except for male Middle Eastern noses (P = 0.01)-were measured as ideal using the Byrd nasal length proportion method. Caucasian and Middle Eastern noses measured ideal using the nasolabial tip projection method. African American female noses measured ideal using the nasofacial tip projection method. Only Caucasian noses were ideal using the lip tangent method.

Conclusions: This study suggests that the ideal nasal length to tip length ratio of two-thirds (67%) has generalizability across these racial groups; the lip tangent is an excellent method for evaluating tip projection in Caucasians; and assessment of ideal tip projection in Middle Eastern and African American groups should use regional midface and lower face anatomy to account for differences in facial morphology.

Background: This study was conducted to compare the incidence of postoperative complications related to blood circulation in the treatment of skin defects through the transfer of ultrathin anterolateral thigh (ALT) flaps or conventional ALT flaps.

Methods: Patients who received ultrathin ALT flap transfer (group A) and conventional ALT flap transfer (group B) due to skin defects at Peking University Shenzhen Hospital from January 2016 to January 2023 were included in this study. The postoperative incidence of ecchymosis, vascular crisis (artery or vein), and flap survival were compared between the 2 groups of patients.

Results: In group A, 27 patients recovered and 8 patients reported ecchymosis. In addition, 32 patients achieved flap survival, 1 patient had partial flap necrosis, and 2 patients had complete flap necrosis. In group B, 61 patients recovered and 6 patients reported ecchymosis. In addition, 65 patients achieved flap survival, 1 patient had partial flap necrosis, and 1 patient had complete flap necrosis. Compared with group B, the incidence of ecchymosis was significantly higher in group A (P < 0.05).

Conclusions: Postoperative blood circulation monitoring (especially ecchymosis) is an important part of postoperative nursing observation in the treatment of skin defects with ultrathin ALT flap transfer. There is no significant difference in the incidence of postoperative vascular crisis between ultrathin and conventional ALT flap transfer. However, the incidence of nonvenous crisis ecchymosis after ultrathin ALT flap transfer is significantly higher than that after conventional ALT flap transfer.