Plastic and Reconstructive Surgery Global Open最新文献

Background: Ex vivo machine perfusion (EVMP) is a versatile platform utilized in vascularized composite allotransplantation (VCA) to prolong preservation, salvage tissue, and evaluate graft viability. However, there is no consensus on best practices for VCA. This article discusses the common components, modifications, and considerations necessary for a successful VCA perfusion.

Methods: A systematic literature review was performed in several databases (PubMed, Scopus, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov) to identify articles published on VCA EVMP (face, limb, abdominal wall, uterus, penis, and free flaps) before August 2022. Graft type and animal model, general perfusion parameters, core components of the circuit, and optional components for enhanced monitoring were extracted from the articles.

Results: A total of 1370 articles were screened, and 46 articles met inclusion criteria. Most articles (84.8%) were published in the last 10 years. Pigs were the main model used, but 10 protocols used human grafts. Free flaps were the most common graft type (41.3%), then upper extremities/forelimbs (28.3%), uteruses (17.4%), and hindlimbs (13.0%). Postperfusion replantation occurred in 15.2% of studies. Normothermic perfusion predominated (54.1%), followed by hypothermic (24.3%), and subnormothermic (21.6%). The majority of studies (87.0%) oxygenated their systems, most commonly with carbogen.

Conclusions: EVMP is a rapidly growing area of research. Leveraging EVMP in VCA can optimize VCA procedures and allow for expansion into replantation, flap salvage, and other areas of plastic surgery. Currently, VCA EVMP is achieved through a variety of approaches, but standardization is necessary to advance this technology and attain clinical translation.

Background: Patients with spastic equinus, equinovarus, and claw toe deformities can experience marked pain and functional limitations in the ability to weight-bear comfortably, ambulate efficiently, or mobilize independently. Seen in 80% of patients with cerebral palsy and 18% of patients with stroke (1, 2), the spastic foot and ankle deformities, and its secondary sequelae of static joint contractures, osseous changes, and chronic pain, are unfortunately common.

Methods: Adult and pediatric patients undergoing combined hyperselective and selective partial motor neurectomies for varus or claw toe deformities were reviewed. Patient demographics and complications were recorded. Pre- and postoperative Modified Ashworth Scale scores were compared.

Results: Twenty-three patients (16 adults and seven pediatric) met inclusion criteria and were included in analysis. At early 6-month follow-up, the mean preoperative Modified Ashworth Score of 2.8 in adult patients and 3.0 in pediatric patients decreased to 0.6 postoperatively. Complications in three adult patients included one patient with temporary dysesthesias to the plantar foot, one with a popliteal abscess requiring incision and drainage, and one superficial wound dehiscence that was managed conservatively.

Conclusions: A combined technique of hyperselective and partial motor neurectomies are effective in decreasing tone in the correction of spastic foot and ankle deformities in both adult and pediatric patients in short-term 6-month follow-up.

Background: International Classification of Diseases (ICD)-10 code specificity is important for detailed diagnostic documentation. Insufficient coding granularity in plastic surgery may hinder accurate clinical documentation, impacting education, research, and patient care. This study examines ICD-10 code modification efforts by plastic surgeons and plastic surgery organizations within the last decade, subsequently detailing the formal proposal process and highlighting potential areas where coding modifications may be explored.

Methods: A retrospective review of all modification proposals presented to the ICD Coordination and Maintenance Committee from March 2013 to March 2023 was conducted. Plastic surgery-related proposals were identified and evaluated for successful implementation. These results were compared to those of other specialties using Fisher exact tests and 2-tailed t tests.

Results: A total of 472 unique proposals were identified and reviewed. Surgeons and/or surgical organizations contributed to 111 (23.5%) novel proposals, 41 (36.9%) of which were initiated by surgeons. Nine surgical specialties and 14 supporting organizations were represented. The success rate for all surgical-related proposals was 85.6%, with an average time to implementation of 24.7 months. Only 2 (1.8%) of all surgical-related proposals pertained to plastic surgery, both of which were successfully implemented.

Conclusions: Though a few plastic surgeons have taken advantage of the ICD code revision process within the last decade, the high overall success rate for surgical-related proposals suggests that this seems to be a feasible method by which plastic surgeons and plastic surgery organizations can bring about useful coding changes that meaningfully impact clinical practice.

Background: Women with spinal cord lesions have loss of sensation in the lower body, negatively affecting sexuality in many ways: decreased, lost, or changed genital sensation and difficulties with orgasm. Restoring genital sensation in men with low spinal lesions using a nerve transfer (to maximize sensation, sexuality, and quality of life [TOMAX] procedure) has shown the potential to enhance sexual functioning and satisfaction. This procedure was adapted to a female version, in which the dorsal clitoral nerve was transferred to the ilioinguinal nerve to restore genital sensation. We report the results of the first female TOMAX patients.

Methods: Four patients with spinal lesions below L1 with unilaterally or bilaterally absent genital sensations and normal sensation in the groin were included. All patients underwent both neurological and psychological assessments preoperatively and at 6, 12, and 18 months postoperatively.

Results: The mean patient age was 53.3 years. Three patients experienced sensations in the clitoris and labia minora at 18 months postoperatively, which led to orgasms in 1 patient. One patient gained no sensation in her genitals but had a surprising side effect: she did not have to catheterize herself anymore.

Conclusion: The female TOMAX procedure is a new promising technique for restoring sensation of the genitals in women with low spinal cord lesions.

With breast cancer cases escalating globally, the risk of uncommon sequelae like cutaneous metastatic carcinoma also rises. The identification of such metastases is essential in posttreatment surveillance. A 73-year-old woman with a history of hypertension and diabetes initially presented with postmenopausal bleeding, leading to the discovery and treatment of endometrial carcinoma via hysterosalpingo-oophorectomy. Nearly a decade later, she developed bilateral breast carcinoma, confirmed via radiology and biopsies, necessitating a bilateral-modified radical mastectomy. Her postoperative phase was complicated by the development of sternum bone metastasis and a peculiar metastatic lesion on the left little finger, presenting as a fungating swelling on the distal phalanx. This lesion was later identified as metastatic metaplastic carcinoma from the breast, a rarity for cutaneous metastases. An amputation of the distal phalanx was performed, but her overall condition worsened. Ten months posttreatment, she was hospitalized with a severely deteriorated condition and died shortly after. This case highlights the insidious nature of cutaneous metastases in breast cancer and the potential for unusual presentations, such as the rare involvement of the distal phalanx. It emphasizes the importance of continuous vigilance in the follow-up of breast cancer patients, particularly when unusual symptoms arise, and underscores the value of a multidisciplinary approach in managing complex metastatic diseases to potentially improve survival outcomes.

Background: The skyline or dorsal tangential view (DTV) and the carpal shoot-through (CST) have been developed to enhance the intraoperative examination of the distal radius's dorsal cortex during open reduction and internal fixation with volar plates. This study aimed to assess the lateral view (LV), DTV, and CST's effectiveness in showcasing screws that penetrate the dorsal cortex.

Methods: Eighty patients, comprised of 42 women and 38 men with an average age of 53 years, underwent volar locking plate fixation for displaced distal radius fractures. The procedures incorporated the use of intraoperative LV, DTV, and CST views. Every view was meticulously examined to record the presence of screws that breached the dorsal cortex of the fractured region.

Results: Only 2 screws were found to protrude the dorsal cortex in the LV, demonstrating 100% specificity and 18.8% sensitivity. On the DTV, 9 screws were detected with the same specificity but increased sensitivity (75%). On the CST, all 12 screws were identified, making for 100% specificity and sensitivity. Of 501 distal screws, 13 (2.54%) penetrated the dorsal cortex, with an average length of 1.34 mm (range, 0.5-2 mm). These screws were subsequently replaced with shorter screws in 12 of 80 patients.

Conclusions: The findings show that the CST and DTV are more precise and accurate than LV in identifying dorsal screw protrusion during distal radius volar plating. To minimize the likelihood of subsequent complications, it is highly advisable to implement these views in all procedures.

Background: The National Surgical Quality Improvement Program (NSQIP) database provides an important resource for determining complication rates and risk factors for surgical procedures. However, NSQIP is limited to 30-day follow-up, and it is unclear whether this is reliable for evaluating prosthetic breast reconstruction outcomes.

Methods: A single-institution, cross-sectional, retrospective review was performed for patients undergoing mastectomy with immediate, prepectoral tissue expander reconstruction. Timing of complications was stratified as early (within 30 days of operation) versus late (after 30 days). Categorical variables were compared using χ² (or Fisher exact) tests, and continuous variables were analyzed using Kruskal-Wallis or Wilcoxon rank-sum tests.

Results: There were 301 patients (509 reconstructed breasts) included with a median follow-up time of 11 months. Of them, 176 patients (58%) experienced a postoperative complication-140 patients (47%) experienced an early complication and 36 patients (12%) experienced a late complication. Patients with late complications had a significantly higher rate of reconstructive failure compared with the early complication group (17% versus 10%; P = 0.001) and were more likely to require a flap (28% versus 7%; P = 0.001) for final reconstruction. Revision surgery rates after final implant placement were higher in the late complication group (36% versus 64%; P = 0.285).

Conclusions: Late complications after prepectoral breast reconstruction have a more prominent impact on reconstructive failure and revisions than early complications. This finding may inform strategies to revise national databases such as NSQIP to include more detailed information and longer capture periods.

Background: Nonbinary individuals assigned female at birth are increasingly presenting for gender-affirming chest surgery (GCS). However, little is known about psychosocial outcomes in this group. We compare patient-reported and clinical outcomes after GCS between nonbinary and binary transmasculine individuals who underwent GCS.

Methods: We performed an institutional retrospective chart review. Demographic information, medical comorbidities, history of gender-affirming medical care, operative details, and complications were collected and compared between nonbinary and binary patients. Two validated patient-reported outcomes measures, the Gender Congruence and Life Satisfaction (GCLS) scale and the chest dysphoria measure were administered postoperatively.

Results: A total of 281 patients were included, of which 40.6% (114) identified as nonbinary and 59.4% (167) identified as binary transgender men. Fewer nonbinary patients used testosterone (P < 0.001). Nonbinary patients underwent a wider variety of masculinizing chest operations than binary patients, with fewer nonbinary patients electing for free nipple-areolar complex grafts (P < 0.001) and more nonbinary patients undergoing breast reduction (P = 0.001). A total of 137 (48.7%) patients responded to postoperative surveys. Nonbinary and binary respondents had comparable scores on the overall GCLS (P = 0.86), GCLS chest subscale (P = 0.38), and chest dysphoria measure (P = 0.40). The absence of nipple-areolar complex grafts was associated with higher GCLS chest scores (P = 0.004).

Conclusions: Nonbinary individuals have similarly positive outcomes following GCS compared with binary individuals. Surgeons should be aware of greater medical and surgical heterogeneity in this population and seek to understand individual patients' goals and priorities.

Background: Representative translational animal models play a key role in vascularized composite allotransplantation (VCA) research. A composite porcine hindlimb flap, previously described, is a relevant preclinical model. However, its bulkiness and the absence of critical immunologic tissues make it less suitable for investigating the unique immunologic features of VCA. We aimed to further develop this model by reducing its bulkiness and by including donor-draining lymph nodes.

Methods: We conducted an anatomic study by harvesting 11 porcine osteomyocutaneous flaps (4 conventional and 7 modified techniques), which were characterized by computed tomography. Furthermore, 8 allotransplantations were performed in Swiss landrace pigs. After the procedure, animals were assigned to a model development and control group (N = 4 per group). No immunosuppression was given, and animals were followed up until grade 3 rejection.

Results: With the modified technique, the flap weight was significantly reduced with a mean weight of 831 g, corresponding to 1.8% total body weight versus 1710 g in the conventional technique, representing 4.2% of total body weight (P < 0.0001). The muscle/bone ratio was reduced from 8.24 (conventional) to 2.92 (modified), (P = 0.03). Histologically, graft-draining lymph nodes showed typical changes related to rejection and no signs of ischemia after in vivo transplantation.

Conclusions: By modifying the surgical technique, the bulkiness of the flap was markedly reduced, without impairing its vascularization and reliably including vascularized graft-draining lymph nodes. Our modified VCA model in the pig presents distinct advantages for surgery as well as immunologic analysis, warranting a large-scale use for experimental reconstructive transplantation studies.